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Clinical & ResearchFull Access

Multidisciplinary Teams Knock Down Barriers to Medication Treatment for OUD


Medication treatment for opioid use disorder is largely underused. The article below is the final in a series of four that explores the barriers to access and offers solutions to help ensure that patients who could benefit from the treatment both understand it and receive it.

Logo: Barriers to Medication Treatment

Each day, more than 130 Americans die of an opioid overdose, according to the Centers for Disease Control and Prevention. In 2017 alone, opioid overdoses claimed the lives of 47,600 people—enough to fill an entire baseball stadium. The need for accessible treatment for opioid use disorder (OUD) has never been so great, but those with the condition face barriers ranging from cost to a dearth of available health professionals who can offer them medications such as buprenorphine, methadone, and naltrexone.

Art: Multidisciplinary Teams

Yet there is hope. Regardless of specialty, discipline, or care setting, health care professionals throughout the nation are coming together to find solutions. They are collaborating to design protocols, launch clinics, enhance training, and forge networks in an effort to increase access to medication treatment and save lives. In so doing, they are shining a light on what multidisciplinary teams can do.

“Improving access to medication treatment is crucial to addressing the opioid crisis, and it requires all hands on deck,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “I encourage psychiatrists to work with other mental health and health care professionals to treat patients with OUD. Multidisciplinary teams need our expertise in the treatment of not only OUD, but also other mental illnesses these patients often have.”

In the Emergency Department

Seven years ago, as the opioid crisis grew and opioid-related visits to emergency departments (ED) began to soar, it seemed only logical to Gail D’Onofrio, M.D., M.S., chair of the Department of Emergency Medicine at Yale School of Medicine, to initiate buprenorphine treatment right there in the ED if patients agreed to it. She and her colleagues joined forces to create a protocol and conduct a randomized trial including 329 patients on the effectiveness of ED-initiated buprenorphine treatment.

They published their results in the April 28, 2015, issue of JAMA. They found that patients who received ED-initiated buprenorphine treatment were more likely to be in treatment at 30 days compared with those who received only information about local treatment options or who received a brief intervention and a referral for further treatment. In a follow-up study published in the June 17, 2017, issue of the Journal of General Internal Medicine, D’Onofrio and colleagues found that patients in the buprenorphine group were more likely to be in treatment at 60 days.

Now hundreds of EDs offer buprenorphine induction to patients with OUD, and D’Onofrio is inundated with requests from hospitals all over the country seeking information and guidance.

“We’ve learned a lot and are disseminating what we know via websites, webinars, grand rounds, and other avenues to try to get everyone up to speed,” D’Onofrio said. “We know medication works, and at this point we don’t consider it optional. The consequences of inaction are that 5% of patients who do not receive treatment after presenting to the ED with an OUD will be dead in a year, but if we give them the medication, they are much less likely to die.

Over the Miles

In 2015, Wells House Inc., a treatment center in western Maryland, found itself without someone who could write prescriptions for buprenorphine after its qualified health professional retired. The center reached out to the University of Maryland School of Medicine for help, and a telemedicine pilot program was born. From their offices in Baltimore, addiction psychiatrists in the university health system conduct full diagnostic patient evaluations, including medical, psychiatric, and substance use histories. They then provide diagnoses and treatment plans for patients that include the use of buprenorphine when appropriate.

APA to Offer ‘Learning Collaboratives’ on MAT

APA members are encouraged to take advantage of 32 virtual learning collaboratives on medication treatment for opioid use disorders to be offered over the next several months.

The learning collaboratives, combining self-paced activities and live interactions with fellow members and experts on medication treatment via conference calls, are being offered by APA as a partner in the Opioid Response Network, a coalition of organizations led by the American Academy of Addiction Psychiatry. The network is a project of the State Targeted Response Technical Assistance Project, funded by the Substance Abuse and Mental Health Services Administration. It provides local training and education free of charge for specific needs at a community level to address the opioid crisis.

Each collaborative is led by a faculty expert who guides participants and supports their efforts. Participants can earn up to 12 CMEs by completing various activities such as watching prerecorded webinars, calling in to office hours, participating in group discussions, and completing an individual project.

If you are interested in receiving information about the collaboratives, fill out the form posted here or contact Eunice Maize at APA at [email protected].

In the December 2018 American Journal on Addictions, the Maryland team reported that 101 (54.7%) of the 177 patients initially enrolled in the program were still engaged in treatment at the three-month mark. Of those, 87 (86.1%) tested negative for opiates.

Since then the telemedicine program has expanded to roughly 450 patients in five counties, including the patients in the original program. So far, the retention rates are similar, said lead author Eric Weintraub, M.D., head of the Division of Addiction, Research, and Treatment and an associate professor of psychiatry at the University of Maryland School of Medicine. “There’s about a 50% retention rate at three months, and of those, well over 90% are opioid-negative,” he said. He added that when patients leave the program, it’s often because treatment is successful. “After a month or two they may leave because they go back to work or go back to their families.”

More recently, the Maryland team received a grant from the Department of Health and Human Services Health Resources and Services Administration, to create a mobile unit in collaboration with the Caroline County (Md.) Health Department. Patients who come aboard a customized van and meet the criteria for OUD teleconference with Weintraub, who can evaluate them and send a prescription for buprenorphine or naltrexone to a nearby pharmacy.

“The data are just starting to come in, but when we ask [patients] if they would have sought treatment if the van hadn’t been there, a lot of them say they would not have just because of difficulties in finding transportation,” said Weintraub. (Psychiatric News will follow up on the mobile unit’s progress in a future issue.)

Through Hubs and Spokes

At Penn State Health, interdisciplinary teams deliver medication treatment through a combination of models that connect primary care sites and hospital systems. One element, the hub-and-spoke model, includes a hub that serves as an intensive outpatient clinic that supports 12 surrounding primary care, ED, and primary psychiatric spoke sites. Patients may receive care across the continuum of the hub and spoke according to individual need. Some patients may start at a spoke and end up needing spoke-to-hub transfer for more intensive treatment. Others may initiate treatment at the hub and transfer to a spoke once stabilized.

Another element is Project Extension for Community Health Outcomes (ECHO), which uses videoconferencing as a platform for telementoring and collaborative care, the better to share best practices among health professionals and monitor outcomes. So far Project ECHO has provided two videoconferencing tele-education sessions on OUD treatment.

“We talk about [the topic] with multiple experts in the room. For OUD there are peer counseling and addiction medicine specialists, and we had psychiatrists come in,” said Sarah Kawasaki, M.D., an assistant professor in the Department of Psychiatry and the Department of Medicine at Penn State. “[Participants] all feel that their type of medicine is supported, and it makes them feel more confident and competent in treating OUD.”

Kawasaki and her colleagues discussed their preliminary results in a paper in the November 2019 Journal of Substance Abuse Treatment. As of April, the hub had treated more than 600 patients, including 352 in active treatment for OUD, and the 12 spoke sites had treated 306 patients. During the first six months of the hub program, 63% of patients who took methadone and 43% of patients who took buprenorphine remained in treatment. ■

“Drug Overdose Deaths” is posted here. “Understanding the Epidemic” is posted here. “Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial” is posted here. “Emergency Department-Initiated Buprenorphine for Opioid Dependence With Continuation in Primary Care: Outcomes During and After Intervention” is posted here. “Expanding Access to Buprenorphine Treatment in Rural Areas With the Use of Telemedicine” is posted here. “Multi-Model Implementation of Evidence-Based Care in the Treatment of Opioid Use Disorder in Pennsylvania” is posted here.