Buprenorphine Grand Rounds Series

Background:

Studies have shown that medication-based treatment for opioid use disorder is effective in a variety of treatment settings. There are several FDA-approved medications for the treatment of opioid use disorder. However, access to these medications varies greatly across different treatment settings. While a number of substance use treatment facilities offer these medications, only a small percentage offer clients a choice of the three commonly used medications. Additional barriers include treatment programs with multiple requirements for accessing medication. Often referred to as “high-threshold” or “low-tolerance” service delivery models, these programs can have a counterproductive effect on treatment outcomes, as individuals often react to the rules and requirements by discontinuing treatment. Quitting substance use without the aid of medication (“cold turkey” detoxification) and requirements for total abstinence from evidence-based opioid medications, continue to be practices in some settings, even though there is no evidence that such practices are effective. In fact, a lack of access to medications results in 65-91% of clients returning to use after detox treatment. There is also a higher risk of overdose for individuals who are treated without medications if they relapse, as their body can become less able to tolerate opioids, and the return to a previous level of use can be very dangerous.

The situation in Cayuga County:

Cayuga County has a low number of providers who offer medications for opioid use disorder compared to other New York counties (adjusted for population). Access to FDA-approved medications, such as buprenorphine (suboxone) or naltrexone (vivitrol), is available in different settings with differing program compliance requirements and wait times. To facilitate same-day access to medications when needed, HEALing Cayuga is partnering with a prescriber to meet that need. Methadone treatment is currently not available in Cayuga County. As patients must typically receive each dose from the treatment provider on a daily basis, this creates a tremendous hardship. Individuals are forced to commute to neighboring counties for their daily treatment regimen, which creates a number of challenges, including the time required, transportation barriers, and work obligations. Efforts are on the way to bringing methadone treatment to Cayuga County.

Addressing the treatment gap:

Only two out of ten people with opioid use disorder receive addiction treatment. Reasons for this huge untreated need include challenges accessing care, lack of flexible treatment options, fear or shame, or criminalization of substance use. While these individuals may not seek out substance use treatment specifically, they often seek other forms of healthcare in settings that can help address substance use, such as primary care and pregnancy providers, or emergency departments.

Substance use treatment in the ER:

Starting treatment for addiction in the emergency room greatly improves the chances that individuals will engage in ongoing treatment and experience recovery from addiction. Many people with substance use disorder are not connected to primary care providers and use the ER for a wide array of healthcare needs. When ERs learn how to effectively assess addictions, provide necessary initial treatment, and refer to community providers for ongoing care, this can ensure that individuals connect with care and reduce repeated visits to the ER. Emergency room personnel often do not have addiction-specific training and may lack experience in making referrals to community-based addiction services. HEALing Cayuga is working with the emergency department staff at Auburn Community Hospital and community partners to address these hurdles that affect both patients and staff. Dr. Ross Sullivan from Upstate University Hospital and Dr. Kavita Babu from the University of Massachusetts will share their experience in developing protocols to provide low-threshold buprenorphine treatment at their emergency departments.

Discussing treatment options with pregnant women:

Nationwide, fewer than 2% of ob-gyns can prescribe life-saving buprenorphine to their patients. In Cayuga County, we are not aware of any. In addition, data shows that the rate of newborns in Cayuga County who were affected by maternal substance use tripled between 2016 and 2018, resulting in a level that is more than double the state rate. During that same period, the rate for New York State (excluding NYC) remained relatively stable. According to an American College of Obstetricians and Gynecologists Committee Opinion, opioid use in pregnancy has escalated dramatically in recent years. The use of pharmacotherapy is the recommended therapy and is preferable to medically supervised withdrawal because withdrawal is associated with high relapse rates, which lead to worse outcomes.

Pregnancy providers are key access points for pregnant women to discuss information about pre-natal substance use treatment options to achieve better health outcomes for mothers and babies. We invite our local pregnancy providers to become a part of this life-saving effort and learn more about how they can incorporate medications for opioid use disorder in their practice to better serve their pregnant patients. Dr. Katherine Callaghan from the University of Massachusetts and Dr. Tamara Olt from the Peoria Women’s Health Center in Illinois will discuss the importance of addressing substance use treatment during pregnancy to improve health outcomes for mothers and babies.

Chronic medical conditions in primary care settings:

Substance use disorders have much in common with other chronic medical conditions identified and treated in the primary care setting. Opioid use disorder can be effectively managed in primary care settings and providing buprenorphine improves care and outcomes of other chronic medical conditions and decreases related mortality rates. Opioid use disorder treatment needs exceed the capacity of specialty programs. Incorporating addiction treatment into the primary care setting can help to meet this need by reducing barriers to treatment, and can reduce the stigma associated with addiction. Dr. Heather McAdam from the Community Medical Center in Aurora and Dr. Glenn Thibault from ConnextCare in Pulaski will address how they have overcome obstacles to providing treatment for opioid use disorder in their primary care practices.