If not us, who? The case for treating addiction in primary care - - PowerPoint PPT Presentation

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If not us, who? The case for treating addiction in primary care - - PowerPoint PPT Presentation

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If not us, who? The case for treating addiction in primary care September 2019 Community Care Network of Kansas Annual Conference Kelly.Pfeifer@dhcs.ca.gov Disclosures: I never received money from pharma. I am not representing the

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If not us, who?

The case for treating addiction in primary care

September 2019 Community Care Network of Kansas Annual Conference

Kelly.Pfeifer@dhcs.ca.gov

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Disclosures:

  • I never received money from pharma.
  • I am not representing the State of California.
  • I spent the first 5 years of my career fueling

the opioid epidemic.

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Beth

Name and picture changed

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The cause was clear… we made a plan.

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California, 2015-2018: Dramatic drop in opioid prescribing

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It’s not just

  • pioids

Credit: Matt Willis, MD MPH

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We won’t stop the deaths until we change

how we think

about addiction

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California Health Care Foundation www.chcf.org

We need three things to survive: food, water and dopamine

How opioids change the brain https://www.youtube.com/watch?v=bwZcPwlRRcc

R Corey Waller, MD

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California Health Care Foundation www.chcf.org

9/9/2019

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Dopamine changes over time

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Addiction is a brain disease: living in a tempest

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www.chcf.org California Health Care Foundation

Medicatio ion c calms t the brain in, f facilit litates p partic icip ipatio ion i in beha havioral h health a h and s d social s suppo pport, a and a d allows r recovery

  • Methadone:

cuts death rates by 67%

  • Buprenorphine: cuts death rates by 50%
  • Naltrexone:

Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies, BMJ 2017; 357;j1550; Larochelle, et al. Ann Intern Med. 2018;169(3):137-145; DOI: 10.7326/M17-3107

works for some populations; no impact on death rates in large, long- term trials

Detox then drug-free tx: 2-3x death rates compared to maintenance

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So how do we build a bigger boat?

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9/9/2019

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Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

AIDS Deaths, United States: 1981-1995

  • 1995: 55,000 AIDS deaths
  • Continuous rise over prior

decade

1995: 55,000 AIDS deaths

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“We’re just one part of the

  • system. We can’t do this

alone.” “They brought this on

  • themselves. They knew the

risks and made their choices.” “These patients are too complex– we don’t have the clinical expertise.” “These patients are too disruptive for our practice.”

Primary care Responses to HIV in the ‘90s

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HIV now

Ubiquitous routine screening Treatment access widespread Almost normal life expectancy

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What can HIV teach us about bigger boats?

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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma
  • 4. Promote harm reduction
  • 5. Don’t do it alone
  • 6. Tackle racism

Lessons from HIV

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1.Screen widely

  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma
  • 4. Promote harm reduction
  • 5. Don’t do it alone
  • 6. Tackle racism

Lessons from HIV

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Screen widely: We can’t help if we don’t know. We won’t know if we don’t ask. Support evidence; support MAT.

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  • 1. Screen widely

2.Make treatment easy to find:

no wrong door

  • 3. Stop the stigma
  • 4. Promote harm reduction
  • 5. Don’t do it alone
  • 6. Tackle racism

Lessons from HIV

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California Health Care Foundation www.chcf.org

NOT <

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Make treatment easy to find. No wrong door.

  • Treat the disease, not the symptom
  • Train and support clinicians
  • If you can’t integrate, coordinate
  • Step-up and step-down care (like any other chronic disease)
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Treatment s starts her here: e: MAT a at e ever ery hea health c care t e touc uchpoint

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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door

3.Stop the stigma

  • 4. Promote harm reduction
  • 5. Don’t do it alone
  • 6. Tackle racism

Lessons from HIV

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Stop the stigma

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Patients need help combatting stigma: friends, family, 12-step groups, treatment centers…

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Words can heal; words can harm

We need to replace this: With this:

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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma

4.Promote harm reduction

  • 5. Don’t do it alone
  • 6. Tackle racism

Lessons from HIV

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Promote Harm Reduction

  • Risky behavior won’t go away
  • Some behaviors are safer than
  • thers
  • Our goal is improved life for people

and communities

  • We should help minimize harm
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We are good with harm reduction – for diabetes.

Cause? Genes, environment, and behavior Prevention? Environmental and behavior change Treatment? Long-term chemical replacement; lifestyle changes Noncompliance: Support small changes. Keep treating.

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Diabetes vs. Addiction: what can you lose? Treatment Custody of children Freedom (probation)

Yes Yes No No Yes Yes No

The list goes on.. housing, family, work, and more

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The cost of expecting perfection

People cut off opioid pain meds are twice as likely to use illicit drugs Veterans: higher risk of suicide and mental health crisis when opioids tapered to zero Half of people discontinued off opioids were stopped abruptly; half of those were admitted to the ED or hospital for opioid-related diagnoses.

Pre-publication from Phillip Coffin’s study of tapering outcomes. Demidenko, M., et al, Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users, Gen Hosp Psychiatry 2017 Jul; 47:29-35, https://www.ncbi.nlm.nih.gov/pubmed/28807135 http://www.bmj.com/content/357/bmj.j1550

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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma
  • 4. Promote harm reduction

5.Don’t do it alone

  • 6. Tackle racism

Lessons from HIV

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Don’t do it alone

  • Warmline: free addiction

specialist expertise to help you with cases and commonly asked questions

  • Resources: SAMHSA,

Provider’s Clinical Support System (PCSS-MAT), CHCF

  • Relationship with opioid

treatment program (step-up and step-down)

  • Telehealth: direct to patient,

e-consultation, or shared management

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https://www.chcf.org/publication/innovation-landscape-telehealth-mat/

Telehealth providers specializing in MAT Telepsychiatry providers adding MAT

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www.chcf.org

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Levels of care: primary care MAT

Level 3 Level 2 Level 1

Hire addiction counselors and/or peers. Train staff and clinicians in management of other SUDs. Contract with counties and plans as SUD treatment provider. 2 clinicians get a waiver. Treat simple OUD; transfer complex patients (persistent + drug screens) to opioid treatment program. Accept bupe maintenance patients. Transition high-dose pain patients onto bupe Train staff in SBIRT screening. Train behavioral staff in motivational interviewing for SUD. Have MA do check-in calls during buprenorphine starts. Do buprenorphine group visits, co-led by clinician and behaviorist.

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HIV care got a bigger boat. What happened?

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Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

AIDS deaths: 1981-2007

  • -- AIDS deaths

Widespread screening Access to effective treatment Anti-stigma campaign Harm reduction Team care

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The French Experience: 80% Drop in Deaths

Heroin OD deaths Methadone treatment Buprenorphine prescriptions

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Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Why not zero?

  • -- AIDS deaths
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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma
  • 4. Promote harm reduction
  • 5. Don’t do it alone

6.Tackle racism

Lessons from HIV

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https://www.youtube.com/watch?v=-4YDUDhMcvM

Apologies in advance: it is impossible to beep out profanity from Wanda

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  • 1. Screen widely
  • 2. Make treatment easy to find: no wrong door
  • 3. Stop the stigma
  • 4. Promote harm reduction
  • 5. Don’t do it alone
  • 6. Tackle racism

Start simple. But start now.

Lessons from HIV

Level 3 Level 2 Level 1

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Helping people recover can support

  • ur own recovery.

Rediscover the joy of medicine. If not us, who?

Kelly.Pfeifer@dhcs.ca.gov