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Medications for Addiction Treatment Best PRACTICE TOOLKIT Medications for addiction treatment Providing best practice care in a primary care clinic Grace Katie Bell, MSN RN-BC CARN PHN Shelly Virva, LCSW FNAP 1 Medications for addiction treatment About the authors Shelly Virva Shelly serves as the Associate Clinical Director and subject matter expert for the National Center for Complex Health and Social Needs within the Camden Coalition of Healthcare Providers. Her passion for social justice and caring for vulnerable patients spans over 20 years working as a licensed clinical social worker. She has an extensive background working with people who suffer from addiction and co-occurring mental health disorders, chronic medical and early life trauma. She also has experience working for a regional payer of both commercial and government plans. As the expert on addiction and co-occurring disorders she was part of an interdisciplinary group working with high cost, high utilizing patients. Additionally, she was part of a multi-disciplinary team that started an ambulatory ICU for high frequency emergency department users and pregnant women with substance use disorder. In her current role she is part of an interdisciplinary team that provides coaching, training and model co-design for vulnerable populations in health systems and FQHCs around the country. Grace Bell Grace “Katie” Bell MSN RN-BC CARN PHN is a nurse consultant with Telewell Indian Health MAT Project offering Technical Assistance, mentoring and training for California Indian Health clinics as they develop Medication-Assisted Treatment programs. Ms. Bell has co-facilitated in the UCLA Hub & Spoke Learning Collaborative and is a monthly participant for UCLA’s Tribal Project Echo for Indian Health primary care clinics throughout California. Katie is currently Nurse Case Manager for the Medication-Assisted Treatment (MAT) program at Chapa-De Indian Health in Grass Valley, CA. Board-certified in Addictions RN, Katie has been working with the medication buprenorphine/naloxone (Suboxone) since a 2001 Phase 3 NIDA clinical trial. Having developed programs for OUD and other substance used disorders in multiple settings including Dept. of Veteran Affairs, the Betty Ford Center, a methadone clinic and now Primary Care, she brings understanding of patient care and advocacy in a variety of health care setting and systems. Katie is also a MAT Nurse Consultant/Clinic Coach for Center for Care Innovations Addiction Treatment Starts Here Primary Care. About the Camden Coalition We are a multidisciplinary nonprofit working to improve care for people with complex health and social needs in Camden, NJ, and across the country. The Camden Coalition works to advance the field of complex care by implementing person-centered programs and piloting new models that address chronic illness and social barriers to health and wellbeing. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to the most vulnerable individuals in Camden and regionally. Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition's local work also informs our goal of building the field of complex care across the country. Launched in 2016, the National Center exists to inspire people to join the complex care community, connect complex care practitioners with each other, and support the field with tools and resources that move the field of complex care forward. Introduction to the MAT 00 best practice toolkit Executive summary This toolkit is designed to help program administration and clinical care teams establish effective programs to treat opioid use disorder using medications for addiction treatment (MAT). It contains a compendium of knowledge from several disciplines and reflects years of experience working in addiction medicine and more specifically, working to care for persons with opioid use disorders. Successful MAT programs do more than just prescribe and dispense medication: they must also be designed to address the complex health and social needs of the patients seeking care. After reading this toolkit, you will better understand best practice dosing and clinical workflows for MAT, and you will also learn how to consider the whole person needs of our patients, challenge the context of stigma within the walls of care, blend the best of dueling recovery ideologies, utilize evidence-based best practices, and incorporate program data for sustainability. Why MAT? Advancements in addiction medicine, specifically the areas of the brain most impacted by addiction, have increased the availability and effectiveness of medications to help treat this disease. Medications for opioid use disorder are evidence-based and, in combination with evidence-based behavioral health interventions, are best practice. In fact, methadone has been one of the most widely researched treatments for opioid use disorder, spanning over 50 years. The findings are consistent across studies, with significant reductions in substance use, criminality, healthcare costs including transmission of hepatitis C and HIV. The data also show a significant increase in employment and overall societal function.1 In 2002, buprenorphine was introduced for the treatment of opioid use disorder. Unlike methadone treatment programs, which requires daily onsite dosing, buprenorphine can be prescribed in office and community settings, significantly increasing access to treatment. “Under the Drug Addiction Treatment Act of 2000 (DATA 2000), qualified U.S. physicians can offer buprenorphine for opioid dependency in various settings, including in an office, community hospital, health department, or correctional facility.”2 CARA (Comprehensive Addiction and Recovery Act) was signed into law by President Obama in 2016. This expanded buprenorphine prescribing privileges mid-level providers such as physician assistants and nurse practitioners, thus expanding access to treatment.3 1 Joseph H1, S. S. (2000). Methadone maintenance treatment (MMT): a review of historical and clinical issues. Mt Sinai Journal of Medicine, 347-64. 2 SAMHSA. (2019, July 23). Buprenorphine. Retrieved from Substance Abuse Mental Health Service Administration Website: https:// www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine 3 CADCA. (2019, July 23). Comprehensive Addiction and Recovery Act (CARA). Retrieved from CADCA Building Drug Free Communities: https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara 3 Medications for addiction treatment Methadone continues to be a highly effective evidence-based treatment for opioid use disorder, however this toolkit focuses on buprenorphine and best practices for its use, in primary care and other office-based settings. How to use this toolkit Medications for addiction treatment programs provide the best care when they are designed using an interprofessional care team of prescribers, nurses, pharmacists, medical assistants, and substance use disorder and behavioral health providers. The collaborative work in MAT programs presents new challenges for busy primary care settings. Often, departments are not expected to integrate care as closely as an MAT program demands. Our hope is that the contents and guidelines embedded in this toolkit will support the unique collaboration strategies of your clinic. Take what you need, modify the documents to fit your program, and start a pilot. There are also many resources embedded within the toolkit for MAT programs in the midst of growth. The MAT best practices toolkit is the result of extensive interprofessional team-based care and collaboration experience, designing programs and learning from our failures as well as our successes. Treating addiction within a primary care setting is often like fitting a square peg in a round hole. Our hope is that this toolkit can provide the practical program development and day-to-day operations information you need to develop a sustainable MAT program. We are committed to making sure every person who suffers from the disease of addiction has readily available access to evidence-based treatments, including medications. Until that time comes, our mission continues. Why the term “medications for addiction treatment”? You have likely heard that MAT stands for “medication-assisted treatment” and may be wondering why in this toolkit we are calling it “medications for addiction treatment” instead. The decision to use this term throughout the toolkit is very deliberate. We hope you, the reader, will start to use medications for addiction treatment as well. Stigmatizing language continues to create barriers for persons with substance use disorders, including preventing access to evidence-based medications and therapies. Changing the words we use matters. It is essential for all of us working in addiction medicine and healthcare in general to use non-stigmatizing language. In a 2017 commentary published in the Journal of Addiction Medicine,4 Dr. Sarah Wakeman writes, “The stigma surrounding the use of pharmacotherapy, in particular opioid agonist therapy, is arguably more potent and harmful than the general stigma about addiction. The most widely held and stigmatizing belief is the notion that medication is simply a ‘replacement addiction,’ ‘substituting one drug for another,’ or even ‘liquid handcuffs.’ Not only does this false notion of replacement or substitution misunderstand the definition of addiction, but it is quite literally killing people. 4 Sarah E. Wakeman, M. F. (2017). Medications for
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