Objectives   Understand the critical importance of philosophy, structure, and access in MAT Share practical tips for starting MAT in your practice Discuss lessons learned with developing a MAT progra

Li, MD, Erica

Weinstein, MD, MPH, DRPH, Lara

English

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Department of Family & Community Medicine Presentations and Grand Rounds Department of Family & Community Medicine 7-23-2020 Beyond The Waiver Training: Practical Tips You May Not Have Learned Lara Weinstein, MD, MPH, DRPH Thomas Jefferson University Erica Li, MD Thomas Jefferson University Follow this and additional works at: https://jdc.jefferson.edu/fmlectures  Part of the Family Medicine Commons, and the Primary Care Commons Let us know how access to this document benefits you Recommended Citation Weinstein, MD, MPH, DRPH, Lara and Li, MD, Erica, "Beyond The Waiver Training: Practical Tips You May Not Have Learned" (2020). Department of Family & Community Medicine Presentations and Grand Rounds. Paper 427. https://jdc.jefferson.edu/fmlectures/427 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Family & Community Medicine Presentations and Grand Rounds by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. BEYOND THE WAIVER TRAINING: PRACTICAL TIPS YOU MAY NOT HAVE LEARNEDLARA CARSON WEINSTEIN, MD, MPH, DRPHASSOCIATE PROFESSOR OF FAMILY MEDICINEDEPARTMENT OF FAMILY AND COMMUNITY MEDICINESIDNEY KIMMEL MEDICAL COLLEGE, PHILADELPHIALARA.WEINSTEIN@JEFFERSON.EDUI HAVE NO CONFLICTS OF INTERESTS TO REPORTBUT WE WOULD LIKE YOU TO TAKE A BRIEF SURVEY…HTTPS://JEFFERSON.CO1.QUALTRICS.COM/JFE/FORM/SV_B9M5MBLOHLARRDTOBJECTIVESUnderstand the critical importance of philosophy, structure, and access in MATShare practical tips for starting MAT in your practiceDiscuss lessons learned with developing a MAT programOVERVIEWThe first visit: obstacles and opportunitiesHome inductionPatient “suitability,” or people can’t recover if they dieThis is not what I signed up for: staff supportUrine drug screens- all you ever wanted to know but were afraid to askDiversion in the real worldSublocadeMOUD and COVID19THE FIRST VISIT: OBSTACLES AND OPPORTUNITIESCORE PRINCIPLES OF ACCESS TO MAT•Make it easier to get buprenorphine than heroin• Recognize the impact of trauma on people’s coping mechanisms• Continually adapt the system to the person, not the other way around• Provide tools and support, do not try to regulate peoples’ drug use• Cultivate compassion and humility•Work smarter, not harder: set yourself, your system, and your patients up for success!WHAT WE KNOW…Addiction TraumaIn Philadelphia communities 69% report > 1 traumaThere would be limited to no addiction w/out traumaPATIENT’S LIFE EXPERIENCESIncreased exposure to trauma Unsupportive home environmentEnvironmental stressors (poverty, violence)Insufficient social supportsAbility to develop and maintain relationships with othersPerson suffering from OUDThis Photo by Unknown Author is licensed under CC BY-SAPart of brain Activity/actionPrefrontal cortex Center of executive functionsRegulates thought, emotions, actions .Promotes flexible,goal-directed behaviorInhibits inappropriateimpulses, Supports attention, reality testing, insightREFLECTIVEAmygdala Triggers emotional responsesDetects whether a stimulus isthreatening.REFLEXIVE/REACTIVEHippocampus Center of learning and memoryConnects emotionto the context/environmentHealthy Brain with top-down regulationAddicted brain with bottom up regulationPart of brain Effect of opioid usePrefrontal cortex Weakens PFCImpaired concentrationWeakened impulse control Impaired modulation of emotional reactionsImpaired decision-making,Lack of insightAmygdala Triggers symptoms of withdraw, anxiety, irritabilityLeads to drug use to avoid pain, not to get highHippocampus Disrupts hippocampus-dependent learningand memoryCan lead to behavioral conditioningCan trigger context-evoked withdraw symptoms, leading to relapseREMEMBER, BEHAVIOR EXISTS FOR A REASON:THE PERSON ISN’T DOING IT…• To irritate you• To be difficult• To sabotage a plan• Because they don’t want to get better• To malinger (mostly)• Because they are trying to manipulate you (usually)THE PERSON MAYBE DOING IT….• Because it’s a survival strategy that kept them alive in the past• They are afraid• They feel ashamed• They feel out of control or powerless• They don’t know how to effectively partner with you to get what they want or needWE CAN HEAL EACH OTHER•We are more than our trauma•Our brains can transform•One interaction can change the trajectoryPATIENT “SUITABILITY”•Trauma informed care•Referral to a “higher level of care” can often result in no care•Have courage, be creative•Use the UCSF warmlineUCSF CLINICAL CONSULTATION CENTER HTTPS://NCCC.UCSF.EDU/•Substance use•Hepatitis C•HIV•PEP/PrEP•Perinatal HIVHOME INDUCTIONHOME INDUCTION TIPSPeople have often tried street buprenorphine with mixed successAlways something to learn for both of youReview standard dosing vs micro-dosing optionsOffer in-office induction is neededProvide rx for comfort meds: clonidine, loperaminde, IbuprofenMake a tailored follow-up/check in planTHIS IS NOT WHAT I SIGNED UP FOR: STAFF SUPPORT•Trauma informed care training•De-escalation training•Regular debriefingMedical staff: It's a very creative response to a complicated way to provide treatment or to meet the challenges of providing treatment, and to do it in an integrative way. It’s already challenging enough to provide medical and behavioral health treatment, but to do it in a way that it’s done sort of simultaneously or in an integrated way seems like a really creative approach to ensuring access.Themes: Philosophy and access (integrated care)Frontline staff: What is suboxone, like really? What is it? Because I think it’s just another drug to put them on for them to get addicted to... I don’t get the purpose. I don’t even get the program. I don’t get it. I know we’s supposed to be nonjudgmental and we’re here to help, but how is we really helping?.Themes: Philosophy and access (harm reduction, low-barrier)Frontline staff: They are trying to help, but they’re not really helping because they’re enabling them.URINE DRUG SCREENS• Observed urine collection can be  humiliating and harmful• ”Discretionary” UDS often show racial bias• Explicit and open conversations• Dignity preserving options • This week or next week?• See handout• https://filtermag.org/urine-screen-drug-treatment/HEROIN CONTAMINATION IN PHILLYDIVERSION IN THE REAL WORLD• Cicero et al 2018• 303 adults with SUD• 58% reported h/o diverted bupeuse• 37% never had a bupe rxDIVERSION IN THE REAL WORLD• 79% to avoid withdraw• 3% because it gives me a better high than other drugs• Cicero et al 2018• Street price of bupe is reportedly lower than heroinSUBLOCADE• Auth boss guide• Patient selection• Ice and ethyl chloride• Supplemental bupeMOUD AND COVID19: AN OPPORTUNITY FOR HEALTH AND SOCIAL JUSTICE• Access• Extended prescriptions• Telehealth deregulation• Infection mitigation• Adjusting drug testing protocols• Virtual support options

Beyond The Waiver Training: Practical Tips You May Not Have Learned

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1434&amp;context=fmlectures

Beyond The Waiver Training: Practical Tips You May Not Have Learned

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