<v ->Hi, my name is Laura Fanucchi,</v> and this will be the PCSS SUD 101 Integrating Opioid Use Disorder Treatment in Clinical Care. I'm Associate Professor of Medicine and Director of the Addiction Consult Service at the University of Kentucky. I do not have any relevant financial relationships with ineligible companies to disclose. The target audience for this presentation and the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders. At the conclusion of this activity, participants should be able to recognize that screening, diagnosis, and treatment of opioid use disorders should be integrated in general medical settings, to discuss models for integrating opioid use disorder pharmacotherapy into primary care settings, emergency rooms, and hospitals, and to review keys to successful OUD pharmacotherapy implementation in clinical practice. Why should opioid use disorder treatment be part of general clinical care? Addiction is a chronic relapsing disorder that's characterized by compulsive drug seeking and use despite adverse consequences. Addiction is considered a brain disorder because it involves functional changes to brain circuits involved in reward, stress, and self-control. It is a treatable chronic medical disease that involves complex interactions between genetics, the environment, and an individual's life experiences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. An individual person's vulnerability to developing a substance use disorder is a complex interplay between genetic and environmental risk factors. And studies suggest that the genetic, environmental, and environmental risk factors contribute about 50% each. So, there are genetic risk factors and genetic differences in terms of opioid receptors, the degree of dopaminegic tone in the brain, other neurotransmitters, and also in an individual person's tendency to have novelty seeking, avoid harm, be impulsive, or have other psychiatric disorders. Similarly, there are environmental risk factors to developing a substance use disorder such as were there availability and presence of drugs in the home environment growing up? Do parents, siblings, or friends use drugs? Did the person have an adverse childhood experience such as sexual or physical abuse or neglect? Are there psychiatric disorders in the home, significant stressors? And was there a significant availability in that person's environment? If we describe opioid use disorder treatment within a chronic disease model, first it might be helpful to think about another chronic medical illness, diabetes. So, diabetes similarly has significant genetic risk. There are also significant environmental and behavioral contributions to an individual's risk of developing diabetes. There are very effective medications to manage diabetes and it's best practice to incorporate supportive behavioral interventions. The goal of diabetes treatment is remission and return to best functioning in life in terms of healthcare and other goals. And we step up and step down the intensity of treatment depending on the individual person's response. There's also a high risk of morbidity without treatment of diabetes, and ultimately over time a risk of mortality. Similarly with opioid use disorder, as we just talked about, there are genetic and environmental and behavioral risk factors. And as we're going to go through today, there are highly effective medications. Supportive behavioral interventions can be integrated with treatment. The goal of treatment is remission, which in the case of opioid use disorder means a cessation of the symptoms of having an active addiction. Depending on an individual's response to treatment, we may step up and step down care. But importantly, opioid use disorder has a very high mortality risk without treatment. In terms of the risk of mortality, there really have been three waves over the last few decades in the rise of opioid overdose deaths in the United States. So, this is a commonly shown graph since 1999 that documents the opioid overdose death rates in the United States per 100,000 population. And you can see that starting in the late '90s, early 2000s, there began to be a rise in prescription opioid overdose deaths. Then in about 2010, heroin reentered the drug supply and overdose deaths due to heroin started to increase. But in recent years since about 2013 or 14, there has been a dramatic increase in the number of opioid overdose deaths, and you can see that the slope increases on the black line is really driven by the increase on the purple line, which is attributed to other synthetic opioids, most commonly fentanyl and illicitly-manufactured fentanyl. There are three FDA-approved medications for the treatment of opioid use disorder, and they have different mechanisms of action, but they all interact with the opioid receptor in the brain. So, if we think about the way opioid medications interact with the opioid receptor in the brain, full opioid agonists and the medications that fall into that category are commonly prescribed opioids like morphine, oxycodone, and then illicit opioids like heroin and non-pharmaceutical fentanyl are all full opioid agonists. That means that with increasing doses, there's increasing stimulation at the mu-opioid receptor and ultimately, the stimulation will continue with increasing doses until the respiratory centers are shut off in the brain and the person may stop breathing and have an overdose. Methadone is one of the FDA-approved medications for treatment of opioid use disorder, and it is also a full opioid agonist. It is also included on a list of the World Health Organization's essential medications, which means that it is highly effective and also should be available in resource-limited healthcare settings. Buprenorphine is a partial opioid agonist, and that means that it has a ceiling of stimulation at the opioid receptor. So, with increasing doses of buprenorphine, there will be increasing opioid effects up until a point and after this point, you can continue to increase the dose, but the stimulation does not get any higher. What this means is the risk of respiratory suppression with a partial opioid agonist like buprenorphine is lower. The other important thing about this particular mechanism of action is that since buprenorphine binds very, very strongly to the opioid receptor, it has very high affinity for the opioid receptor as well. If a person who has opioid use disorder, and is opioid dependent, and has stimulation of the opioid receptor at this level from full opioid agonists, if we give buprenorphine when the person's brain is at this level of stimulation, you drop the level of stimulation to here because the buprenorphine will displace the other opioid agonists, and the person may experience a precipitated withdrawal. However, if a person who is physically dependent on opioid agonists is already in withdrawal, let's say their level of stimulation is here, and they may be having withdrawal and feeling very ill. If we administer buprenorphine at that point, the buprenorphine will bind to the opioid receptors and stimulate, and the withdrawal will be relieved. Buprenorphine is also on the list of World Health Organization essential medications. The third FDA-approved medication for relapse prevention in opioid use disorder is an opioid antagonist, and that is naltrexone. So, what that means is that it does fit on the opioid receptor and bind very strongly, but it has no opioid stimulation. So, with increasing opioid dose of naltrexone, there is no stimulation at the opioid receptor. Buprenorphine and methadone for the treatment of opioid use disorder are highly effective at reducing mortality. So, if we set, for example, the risk of death in the general population at any given time to one, if we standardize the risk of death to one, then persons with opioid use disorder have more than a six fold time the risk of death at any given time than the general population when they are not on treatment with medications, specifically buprenorphine and methadone. Buprenorphine and methadone, when a person enters treatment, their risk of death does not go back to one out of the general population, but is decreased more than 50%. So, the risk of death is decreased more than half by these medications. And the person's risk of death when they are receiving medication for opioid use disorder is a little less than twice that of the general population. There are many other improved outcomes with methadone and buprenorphine, in particular they're associated with decreased illicit opioid use, crime is reduced by half, there's decreased risk of infectious disease transmission like HIV and hepatitis C, there's increased retention in treatment, and improved social functioning. Unfortunately, despite the fact that we have and have had for decades effective medications for treatment of opioid use disorder, they have yet to reverse the rise in mortality. So, in 2020, there were an estimated 84,000 total overdose deaths, and in 2021, we surpassed 100,000. For context, there were 35,000 motor vehicle deaths in 2015. The under-utilization of medications for opioid use disorder is very dramatic. So, there was a recent large scale retrospective review that found that only about 15% of patients with opioid use disorder receive one of the FDA-approved medications. About 12 and a half received buprenorphine or methadone, and about two and a half received naltrexone. The impact of these barriers is very significant. About nine of 1,000 Medicaid patients have opioid use disorder, but less than one receive medications for opioid use disorder. Also, individuals in rural communities are significantly less likely to receive treatment than those in urban counties. And there are also well-documented disparities in the rates of Black and non-White minority populations receiving buprenorphine treatment compared to White populations. In addition, patients presenting to an ER with nonfatal opioid overdose, more than 5% will die within one year, and it's overall a very young population with a median age of 39. Unfortunately, patients hospitalized with complications of opioid use disorder frequently do not receive life-saving medication for opioid use disorder as part of their care during an acute hospitalization. To frame the next part of the presentation, we're going to use a clinical case to illustrate how persons with opioid use disorder can interact with the healthcare system at many different points. And all of these places are opportunities to screen, diagnose, and initiate treatment that can save lives. At age 18, Adam graduated from high school and planned to start college. During high school, he did experience some binge drinking at parties and he noticed at the time that he liked the effect on anxiety. Over the summer before starting college, he injured his back and received a prescription for hydrocodone for the first time. When he took the hydrocodone for pain, he noticed an immediate sense of energy and anxiety relief with taking it. He felt like all of his problems suddenly went away. At the same time, his parents had frequently fought about their alcohol use when he was growing up, and during high school he had a friend that died in an alcohol-related car accident. So, he felt like those experiences kind of showed him some of the consequences of heavy alcohol use, and he was cautious about heavy drinking. So, though he liked some of the effects of alcohol, seeing some of these potential problems made him cautious. He didn't see some of these potential problems with hydrocodone. During college, Adam began buying opioid pills intermittently for recreational use. He found that the frequency of his use escalated, he began to lose control. He began to have cravings for the prescription opioids and he began to use intranasally. His grades began to slip. He was having trouble with money, frequently asking his family for money. And when he went home for a break, his family noticed that really, he seemed different and that he didn't seem as well as he'd been doing before. His family expressed concerns. They brought him to his primary care clinician over the summer because he seemed like he really wasn't feeling well. So, when Adam visits the primary care clinician, that is an opportunity to address the opioid use disorder in a primary care setting. And screening questions were part of his initial visit. So, in primary care settings, we'll go through opportunities for screening, assessment, diagnosis, and treatment initiation as well as risk reduction. There are many options for screening, but one validated option is called the NIDA Modified Assist, and this is available online and it was adapted from the WHO Assist version three. It is the clinician screening tool for drug use in general medical settings and essentially goes through four questions. In the past year, how often have you used the following? And it asks about the level of alcohol use, tobacco products, prescription drugs for non-medical reasons, and illegal drugs. Screening can identify patients who may have diseases or conditions related to their substance use. It is expected that general medical settings include routine screening for common treatable conditions like cancer that are associated with significant morbidity and mortality. And screening for substance use can identify it in patients who wouldn't otherwise discuss it or maybe connect it with the negative consequences that they're experiencing. So, once Adam disclosed that he had been using prescription drugs for non-medical reasons on a daily or almost daily basis, that was an opportunity for the primary care provider to take an assessment. An assessment of opioid use disorder includes taking a full history and doing a physical exam. So, a substance use history would include the age of first use, the route, the frequency, the quantity of use, any history of tolerance, withdrawal syndromes, any history of overdose. And the substance use history should include all types of substances that the person may have tried in his or her life. The history also includes a mental health and psychiatric history. And substance use disorders can be explored and added to family histories during a primary care visit. There can be a brief trauma history as well added to the social history as early life trauma is associated with increased risk of developing substance use disorders as an adult. The physical exam includes an evaluation for signs of opioid withdrawal, intoxication, as well as injection use in addition to the other elements of a typical physical exam. Opioid use disorder is diagnosed using the DSM-5 criteria. The DSM-5 criteria include 11 criteria chunked into three buckets, which are the physiologic sequela, a loss of control, and adverse consequences. A quick way to summarize that is with the three Cs, loss of control, cravings, and consequences. So, the physiologic sequela with opioid use disorder are the development of tolerance of increasing doses of opioids to achieve the same effect, the development of withdrawal when opioids are not present, and the development of cravings, of intense cravings and desire to use opioids. The cravings can be very consuming and prevent the person from being able to think about anything else. An individual then develops loss of control of use where they spend greater amounts of time than intended finding, using, or recovering from substance use. There's a persistent desire to decrease, but they're unable to cut down. And in addition, there may be continued use despite adverse consequences. So, the opioid use may cause the person to fail to fulfill responsibilities like at work, or school, or in family life. They may use opioids when it's otherwise physically hazardous. They may have social interpersonal problems from use and continue to use despite these problems. And it may cause them to give up or decrease activities that are otherwise important to them. As part of the assessment, there should be a laboratory evaluation, but it's important to note that if a laboratory evaluation is not possible immediately, that should not delay the treatment initiation for opioid use disorder. But a laboratory evaluation for somebody with opioid use disorder should include basic testing like a CBC and a comprehensive metabolic panel, screening for HIV, viral hepatitis, and sexually transmitted infections, pregnancy testing for persons of childbearing potential, urine drug testing. And it's important to note that point of care testing at this time, there is no approved fentanyl point of care test. And so, in order to detect fentanyl, which is one of the most common opioids in the supply today, the urine must be sent for confirmatory testing. It's important in states that have the prescription drug monitoring program, which should be the majority of states at this time, to review that information as well. At this point, the provider should engage the patient in shared decision-making in terms of treatment planning or referral once the patient has been diagnosed with an opioid use disorder. So, the presence of any two of the criteria of the DSM-5 criteria can diagnose a person with a mild opioid use disorder. But it's important to note that for a person who's chronically prescribed opioids and only has tolerance and withdrawal when the opioids are taken away, but they never have any of the other symptoms of opioid use disorder and they take their medications as prescribed, that person does not have an opioid use disorder. They have physiologic dependence, which happens as a consequence of the way opioids work. The presence of more than a four or five of these criteria diagnoses a person with a moderate opioid use disorder, and the presence of six or more characterizes a severe opioid use disorder. When the provider goes through the criteria with Adam, it's clear that he's developed tolerance, withdrawal, and cravings. He feels that he's lost control of use, he's trying to cut down, but he's really had trouble, and he's having some adverse consequences in terms of family members being concerned, he's not spending as much time with friends, and his grades are slipping. And he's continuing to use despite these problems. So, the provider diagnoses Adam with a moderate to severe opioid use disorder. And the clinician then discusses with Adam treatment planning or referral using shared decision-making. So, at this point, it's important to explain the options in terms of treatment with medication for opioid use disorder, review the risks and benefits of each and the differences, how to access the medications, and what to expect when entering and staying in treatment with those medications, and to explore patient preferences and beliefs previous what they may have heard before regarding the treatment options. There are a lot of misconceptions and stigma in various communities with respect to buprenorphine and methadone treatment, and it's important to explore what patients may have heard already as an opportunity to correct misconceptions. In addition, the clinician should explore experiences that the patient may have had already with mental health treatment, whether they would like to engage in mental health treatment at the time, whether they're interested in exploring recovery supports in the community, and also provide other referrals for other ancillary services including referral to syringe service programs if appropriate, and harm reduction. Any patient with opioid use disorder or any patient who may have a friend or family member or anyone really in the community should receive opioid overdose prevention and education as well as naloxone prescription or distribution in the clinic. So, I wanted to go through some of the important differences in the medications for opioid use disorder. And these are some of the issues, some of the things that can be discussed with patients in a primary care setting. So, to summarize, methadone and buprenorphine both treat withdrawal, they decrease cravings, they treat pain, they're associated with reduced infection and reduced crime. For methadone, there's no withdrawal needed to initiate. And for buprenorphine there's a short period of withdrawal that's typically required in order to initiate buprenorphine and that's because of the partial agonist mechanism of action that we went through before. In order to access treatment with methadone for opioid use disorder, it can only be dispensed through a licensed opioid treatment program. Those are regulated at both the federal and state level, and patients have to attend daily for the first 90 days. Buprenorphine, on the other hand, is typically office-based. It can be prescribed in an office-based setting, and the patient can pick up their prescription at a pharmacy. The prescriber is required to have an additional waiver on their DEA license called an X-waiver. And as we've talked about, both methadone and buprenorphine are associated with reduced mortality. Naltrexone, on the other hand, does not treat withdrawal. In fact, it's required that the patient go through a period of seven to 10 days of withdrawal before naltrexone can be started. Naltrexone may decrease some cravings somewhat for some patients with opioid use disorder, it does not treat pain, and we do not have data to know whether it's associated with reduced infections or reduced crime. It is not a scheduled medication, and so it can be prescribed by any clinician in any doctor's office without special license. We don't know if there's an association with mortality differences with naltrexone. There was a secondary analysis done of a large head-to-head buprenorphine and naltrexone study that suggests that it may increase the risk of overdose compared to buprenorphine. There are several examples of primary care-based integrated models for opioid use disorder treatment, but overall, these models typically combine pharmacotherapy with buprenorphine or naltrexone. A reminder that methadone cannot be prescribed for opioid use disorder in primary care settings. And that it also includes clinician and community outreach and education, coordination and integration of opioid use disorder treatment with other medical and psychological needs as well as integrated psychosocial services. One note here is that as mentioned, there is a special license on the DEA that is required to be able to prescribe buprenorphine for opioid use disorder in an office-based setting and it's called the X-waiver. Recently and previously prior to April 2021, clinicians had to complete an additional eight hours of training for physicians and 24 hours for physician assistants and nurse practitioners in order to receive that X-waiver from the DEA. But in April 2021, there was an exemption process identified or made by the federal government in order to allow people to receive the X-waiver without completing those hours of training by submitting a notification to SAMHSA to receive the X-waiver. When the X-waiver is received through that pathway without completing the treatment, the prescriber is limited to prescribing for 30 patients at any given time. Once the training is completed, the prescriber can then apply for the X-waiver that allows prescribing up to 100 patients at a time. Office-based opioid treatment is one example of these integrated models, and it's the most common example that we see in various parts of the country. In terms of the medications provided in office-based opioid treatment, it is typically buprenorphine, which is prescribed during office visits. There's coordination and integration of care with other aspects of primary care. And some practices designate specific clinic staff members to coordinate this aspect of the care provided. Office-based opioid treatment includes medication management with the buprenorphine prescribing, which is onsite brief counseling by the prescribing clinician or other staff. And typically, for patients that need more intensive mental health treatment, the patients are referred elsewhere for continued mental health treatment. Some examples where office-based opioid treatment has been adapted in more specific settings is in HIV care. There's a buprenorphine HIV evaluation and support collaborative, that integrated buprenorphine treatment in HIV primary care settings. And the Massachusetts Model is a specific model developed in Massachusetts where a nurse care manager is really the coordinator of the OBOT program and frequently meets with the patients, and the clinician is more the prescriber of the medication along with completing brief medication management visits with the patients. Hub and spoke is another model for integrating buprenorphine treatment in general medical settings. The hub is a centralized intake with typically more specialized addiction care that can manage buprenorphine inductions. And then when patients are then referred out to spokes, which are community care providers for ongoing management, patients can be triaged to the hub or the spoke based on the complexity of care at the initial screening. And patients can move between levels based on their changing needs. A hub is commonly an opioid treatment program that also prescribes buprenorphine. There's typically a nurse case manager and/or a care connector who may be a peer or behavioral health specialist. The hub can provide consultative services for the community care providers at the spokes. They can be available to manage clinically complex patients, and they can also if patients need to transition to methadone from buprenorphine, that is also available at the hub. In Vermont, there's a CMS State Medicaid waiver to allow reimbursement for this hub and spoke model. Psychosocial services are typically embedded within the spoke site and include social workers, counselors, and community health teams. And the hub participates in outreach to community prescribers to increase the pool of prescribers with buprenorphine waivers. So, in the primary care setting, once the clinician and the patient have decided that it's appropriate to move on to initiating buprenorphine treatment, the first step is to determine whether they'll be a home or an in-office initiation. Patients may have had prior experience with buprenorphine and may be perfectly appropriate for a home initiation. The patient must be in at least mild to moderate opioid withdrawal in order to begin buprenorphine. And the more severe the withdrawal, the greater the relief when buprenorphine is begun. The clinician can review supportive medications to manage withdrawal symptoms like nausea, diarrhea, muscle aches, anxiety. Some common medications that are used for supportive care are loperamide for diarrhea, ondansetron for nausea and vomiting, methocarbamol for muscle spasms, hydroxyzine for anxiety, as well as ibuprofen or acetaminophen for the muscle aches. Educate patients that withdrawal symptoms typically begin within about 12 to 24 hours after the last dose of a short-acting opioid like heroin or fentanyl. Patients with opioid use disorder will typically be very familiar with when they typically begin to feel uncomfortable after their last use and when they need to dose themselves again. And so, you can talk through with your patient their typical timing of symptoms to help them determine when would be the best time to begin buprenorphine. For patients that are on long-acting opioids like methadone or extended-release opioid formulations, withdrawal symptoms will typically begin about two to four days later after the last dose. It can be challenging to transition a person from higher doses of methadone to buprenorphine. And typically, when patients want to switch pharmacotherapies, the patient is tapered down on the methadone to a dose of less than 60 milligrams before initiating buprenorphine. There are examples of transitions at higher doses, but it can be complicated. Prior to initiating buprenorphine, the patient should be counseled on the timing of initiation, the potential for precipitated withdrawal with initiating buprenorphine, the role of behavioral management, a treatment agreement, reviewing the prescription drug monitoring program, and also which labs will be reviewed. The clinician should always write a prescription or dispense naloxone for any patient with opioid use disorder. And of course, the final step is writing the buprenorphine prescription. Opioid withdrawal is measured objectively with the Clinical Opiate Withdrawal Scale most commonly. The COWS score has several physical criteria. It is easily found on MDCalc or other common websites, and the criteria are heart rate, sweating, restlessness, pupil size, myalgia, runny nose or tearing, GI upset, tremor, yawning, anxiety, and gooseflesh. And depending on the number of symptoms and the severity, the score goes from mild to moderate to severe. Typical initiation involves giving the first dose of buprenorphine when the COWS score is above eight to 12. With the influx of fentanyl into the supply, there's suggestion that erring on the side of more severe COWS scores may improve the success of buprenorphine initiation. For patients who maybe have already been through withdrawal potentially in a facility that does quote-unquote detox or even in a jail facility and if they're released, they may have already gone through the most severe parts of withdrawal and they have lost physical tolerance and are no longer physically dependent. And so, their COWS score will be low. If someone meets criteria for an opioid use disorder, they are no longer physically dependent and they still can be eligible for treatment with medications for opioid use disorder. So, if someone's COWS score is less than eight and there's no self-reported opioid use in the past three or plus days and the clinical point of care urine drug screen is negative for opioids, remember that fentanyl is not detected by current point of care testing available, then you would initiate with a lower dose as we'll discuss in a minute. So, suggested initiation and stabilization dosing schedule, and this can be tailored to the patient. And there are other other examples that are being developed and are out in the literature now with higher or lower called macro or microdosing available, particularly tailored to patients that may be using fentanyl or to facilitate transition onto buprenorphine while the patient continues to receive full agonist in an inpatient setting. So, a typical initiation dose would be about two to four milligrams once the patient already has a COWS score of eight to 12. And then you might wait 45 minutes and give another four milligrams. And the maximum dose typically on day one is about eight to 12 milligrams. Day two, the patient is instructed to take the full amount that they took the day before, all at once in the morning and then they can take another four milligrams if needed. And so, the typical dose on the second day is 12 to 16 milligrams. On the third day and forward, the patient should take on the third day, the patient should take the full dose they took the day before, and they can take an additional four milligrams if needed. But at that point, if a patient has achieved 16 milligrams, it's typically recommended that they continue at that dose. Although the patients can increase about four milligrams a week if needed until 24 milligrams. For patients that have no tolerance, for example, those that have completed withdrawal in a controlled setting, the recommended initiation dose would be much lower at .5 to one or two milligrams, and you would not go up as fast, you would titrate to effect, make sure there's not too much sedation. If cravings are still present, the dose can be increased slowly. Home initiation is a perfectly reasonable option with proper patient education. So, office-based initiation can be a barrier to treatment starts. And trials of home versus office-based induction demonstrate comparable retention rates and safety. So, patients that may be good candidates for home initiation are able to understand the initiation process, they may have prior buprenorphine experience, they are able to contact the provider with problems, and that the provider is available for phone consultation. There are freely available examples and templates to share for patients beginning buprenorphine treatment at home. This is an example from Yale University. It is a patient-facing flyer to help guide the patient through home initiation of buprenorphine. Typical buprenorphine treatment phases in the office-based setting include the traditional initiation of over one to three days, and the dose should be titrated to effect and to treat to cravings. The average dose of buprenorphine is typically 16 milligrams a day. Stabilization and maintenance then is ongoing, and treatment should be combined with random urine testing and counseling if available. But it's important to note that not having counseling availability should not prevent treatment with medications. And the prescribing clinician can complete brief counseling with medical management as part of the visits for buprenorphine treatment. Importantly, patients should be able to continue buprenorphine for as long as they continue to benefit. So, now we'll go back to our case and discuss what may have happened if Adam had not gone to primary care. But actually when he went home, he had been trying to decrease his opioid use and experienced withdrawal, lost physical tolerance, and when he next used, he experienced the first overdose and was brought to the emergency department. Fortunately, a family member had naloxone because they had been worried about him and had went to a training and received a naloxone unit, and so he was revived and brought to the emergency department. The national rate of opioid-related inpatient stays and emergency department visits has been increasing over the last couple decades along with the opioid epidemic. As in overall healthcare, there's a significant emergency room and hospital opioid use disorder treatment gap. So, this is a study of over 6,000 Medicaid enrollies in Massachusetts that had an emergency department or inpatient encounter for opioid overdose, and only a third received any form of medication for opioid use disorder after the overdose. In another study of 17,000 opioid overdose survivors that had an ambulance or hospital encounter, again only a third received medication for opioid use disorder over the 12 months of follow-up. And importantly, the mortality at 12 months was 4.7 deaths per hundred person years. There was an association of medication for opioid use disorder with reduced mortality, so those opioid overdose survivors that had received methadone treatment had a 50% reduction in mortality, and those that had received buprenorphine had an associated reduction in mortality of 37%. Naltrexone numbers are limited by the small sample in that study. This was a large study of emergency department-initiated buprenorphine treatment where patients who presented to the emergency department were randomized to referral, brief intervention, or buprenorphine initiation in the emergency department. And those that had received buprenorphine in the emergency department were dramatically more likely to be engaged in treatment at 30 days. There are a number of examples publicly available, but this is one from Yale as well that is a protocol for guiding ED-initiated buprenorphine for healthcare settings that are interested in integrating buprenorphine treatment. It really should be part of standard emergency room care because it is so life saving. There are a number of resources to support the implementation of opioid use disorder treatment initiation in the emergency room, and these are just some examples here. There's a SAMHSA guide Use of Medication Treatment in Emergency Departments. There's ED Bridge, which started in California, which is a very comprehensive how-to guide and these are consensus recommendations on the treatment of opioid use disorder in the emergency department. Emergency departments can identify persons with opioid use disorder, initiate treatment with buprenorphine or methadone. They can provide overdose education and naloxone distribution and connect patients to continued treatment。 If patients are hospitalized, opioid use disorder treatment should be integrated in general hospital care. So, in the hospital setting, similarly as in primary care settings, there should be screening, assessment, diagnosis, and treatment initiation, as well as referral after discharge to continued care. There are some additional considerations in the hospital like co-morbid acute medical illnesses, appropriate management of pain, and there's often stigma among hospital providers and staff. On the positive side in the hospital, the patient can be closely monitored and so these additional considerations can be managed easily. In recent years, a number of hospitals have begun addiction consult services, which are interprofessional groups of providers and other clinicians that provide comprehensive care for substance use disorders in the acute care hospital. Typically, addiction consult services involve a medical clinician like a physician, advanced practice nurses, physician assistants, case managers, which may be social workers or nurses, peer support specialists, which are persons with lived experience who can share their own stories and provide support to patients with opioid use disorder, as well as pharmacists. The addiction consult services focus on initiation of medications for opioid use disorder. They offer harm reduction and referral to continued treatment. There are other inpatient models besides addiction consult services, that includes psychiatry, consult liaison services, as well as community-based provider and reach to hospitals. Addiction consult services are associated with improved treatment engagement 30 days after discharged, and they're also associated with reduced 90-day readmissions for people who use drugs and are admitted with serious infections like endocarditis and osteomyelitis. Critical elements of integrating opioid use disorder treatment in hospital settings are very similar to those for integrating opioid use disorder treatment in primary care. Pharmacotherapy is offered, both buprenorphine and methadone can be initiated for opioid use disorder. And on discharge, buprenorphine can be prescribed by wavered providers. Methadone, again cannot be prescribed, but patients can be referred to ongoing treatment at licensed opioid treatment programs. In the hospital, there's coordination and integration of OUD treatment with other medical and psychological needs. The clinician and community education and outreach should be provided as well as integrated psychosocial services. Some of the management considerations in the hospital, when a person is admitted with opioid use disorder, they may be hospitalized for a reason that's unrelated to their opioid use disorder, but either way, or they can be admitted with a complication of opioid use disorder like an injection-related infection or an overdose. Clinicians should strive to maintain physical tolerance for patients with opioid use disorder because loss of tolerance increases the risk of overdose after discharge, patients withdrawal should be treated, they can be managed with full agonists as well as buprenorphine or methadone with the patient's consent. Withdrawal is very painful, and so management of acute pain will be challenging if withdrawal is also present and not managed. Higher doses of opioid agonists are likely needed for management of acute pain in patients who have opioid use disorder because they have higher opioid tolerance. And giving patients with opioid use disorder adequate doses of opioids to manage withdrawal and pain will not make the opioid use disorder worse. This is a common misconception and a reason why opioids are sometimes restricted in the hospital setting to persons with opioid addiction, but in fact that practice not only increases patient suffering, but may increase harm by removing physical tolerance and then increasing the patient's risk of overdose with return to use. When managing acute pain, it's also important to utilize multimodal adjuncts like nonsteroidal anti-inflammatory drugs, acetaminophen, sometimes nerve blocks and other agents. Acute pain management for persons receiving buprenorphine is certainly feasible and doable. So, first, it's recommended to discuss options for pain management with patients, and it's generally recommended to continue the buprenorphine if possible, as well as using non-opioid adjuncts and additional full opioids can be given on top of buprenorphine and still deliver effective analgesia. So, the buprenorphine analgesic effect is about six hours, which is significantly shorter than the effect on treating withdrawal and cravings, which is more like 30 to 36 hours. So, the daily dose of buprenorphine can be split into BID or three times a day dosing, and the dose can be increased in the short-term to facilitate additional analgesia. If buprenorphine must be stopped for a patient specific reason, then full agonist should be provided in the interim to maintain tolerance and control pain. And then buprenorphine reinitiation should be planned when it's possible. There are numerous opportunities to improve care and reduce harm in all healthcare settings. Overdose education and naloxone distribution should be an essential component of providing care to any person with opioid use disorder or any person at risk of overdose in primary care, emergency departments, hospitals, pharmacies, syringe service programs, and health departments, and anywhere else. Safer use education should be provided as well. And screening for HIV, high viral hepatitis, and sexually transmitted infections should be offered. A critical component to reducing the stigma associated with opioid use disorder and medication treatments for opioid use disorder is changing language, using person-centered language whenever possible, not referring to people as clean or dirty, and other important areas to reduce the stigma that patients experience. In the future, we hope that medication for opioid use disorder is accepted and recognized as an essential treatment in the recovery community, in the criminal-legal system, in the healthcare system, and in broader society. That diagnosis, management, and treatment of opioid use disorder is included in all general medical settings. And that we approach opioid use disorder as a chronic disease where treatment includes being able to receive medication for opioid use disorder as well as treatment for other medical illnesses as long as the person continues to benefit from that treatment. This last slide includes some implementation resources that are available online for further reading about integrating opioid use disorder treatment in general medical settings. Again, thank you all for participating in this program. And don't hesitate to reach out to PCSS, sign up to participate in the mentor program, or join the PCSS Discussion Forum. Thank you.

opioid use disorder treatment

clinical care

primary care

emergency rooms

hospitals

addiction

medications

buprenorphine

overdose education