IN 2016, providers at Dell Seton Medical Center at The University of Texas at Austin came together to work on an ambitious agenda. They wanted to create a multidisciplinary team to initiate (and bridge) buprenorphine treatment for hospitalized patients with opioid use disorder.
They decided that team members would include RNs, NPs and PAs, social workers, pharmacists, and physicians from different specialties. And they developed a series of milestones they wanted to achieve, including administering buprenorphine to at least 50% of eligible screened patients.
After a year of planning, what came to be known as “the B-Team” (for buprenorphine team) was launched in November 2017 and has since proved very successful. But team member and hospitalist Christopher Moriates, MD, associate chair of the internal medicine department and associate dean for health care value, says there is one big takeaway from all that planning and development: You don’t really need it.
“Just get started with one patient,” Dr. Moriates suggests. “Treat that person, learn about that treatment and then roll out a system, and don’t let a lack of infrastructure get in the way of prescribing.”
“Don’t let a lack of infrastructure get in the way of prescribing.”
Christopher Moriates, MD
Dell Seton Medical Center
He uses this analogy: While physicians would love to offer patients with diabetes plenty of support and counseling, “no physician would ever decide to not prescribe insulin if such services weren’t in place. We want doctors to prescribe buprenorphine when appropriate, no matter what.”
That treatment, the evidence shows, clearly saves lives, Dr. Moriates adds. “Then, if you can develop other services that benefit patients, that’s great.”
Planning to be phased out
According to Dr. Moriates, team members from the start were guided by one founding principle: Any model of buprenorphine treatment they created couldn’t rely on formally-trained, board-certified addiction medicine expertise.
“Most hospital models are led by a board-certified addiction medicine physician, and that is great,” he says. “But it’s not really feasible to scale in most hospitals in the country—and certainly not here in Texas” due to the shortage of board-certified specialists. Relying solely on specialists, he adds, reinforces the misconception that buprenorphine is difficult or dangerous to order and administer. Instead, B-Team specialties include hospital medicine, psychiatry and palliative care.
“Palliative care has a lot of pain management expertise,” he says. “Each specialty brings different skill sets and perspectives, particularly as we were learning along the way how to set up protocols.”
Team members also spent a lot of time debating how to reach this ultimate goal: “Start this movement, but plan toward being able to phase out the B-Team,” says Dr. Moriates. The idea was to bring so much enthusiasm, demonstrate so many successful treatments and train so many other providers that, eventually, those clinicians would step up, begin initiating buprenorphine themselves and get their own X waiver to bridge patients.
But how best to do that? The team decided to remain a volunteer service instead of moving to a formal addiction consult service. In an article in the December 2021 issue of the open access journal Healthcare, team members spelled out the drawbacks of remaining a pseudo-service. For one, team duties and presentations can be tough to work into regular day jobs. And a volunteer team can’t provide 24/7 coverage.
There was, however, one decisive downside of becoming a formal service. “(H)aving a consultation service,” team members wrote in Healthcare, “may work against the goal of expanding clinicians’ comfort and proficiency with managing buprenorphine.” If providers at the medical center couldn’t offload buprenorphine prescribing to a formal service, OUD treatment for hospitalized patients might more easily become hardwired as the new standard of care.
Breaking the stigma
More than four years later, that strategy of not creating a formal service has paid off. Most hospitalists in the academic center now routinely initiate buprenorphine themselves, and many have their own X-waiver to write discharge bridging orders. While the goal of having every hospitalist X-waivered had to be postponed due to the pandemic, Dr. Moriates believes that goal will be reached this year.
The B-Team set itself another critical goal, that of breaking the cycle of stigma that fuels mutual mistrust between providers and hospitalized patients with substance use disorders. To help foster patient trust, the B-Team now includes a chaplain and a peer recovery coach. Those coaches, according to a writeup the team published in March 2022 in the Journal of Hospital Medicine, “connect patients with people in the local community with lived experience and serve as ‘culture brokers.’ ”
Then there’s the formidable stigma that health care workers bring to patients with opioid use disorder, the idea that patients are too far gone or only drug-seekers.
“It always sounds like we’re over-playing the transformation we’ve seen over the years just by virtue of doing this work,” Dr. Moriates says. “But we have seen impressive cultural changes.”
Yes, he and his colleagues have done a great deal of education, and they have changed the language providers now use, both in conversations with (and about) patients with opioid use disorder and in charts. “But the biggest way we combat stigma is having success stories,” he says. “Physicians and nurses see the benefits of starting patients on buprenorphine, and that really changes the narrative.”
Who can call?
Putting a peer recovery coach on the team was one change team members made since the service went live. They also did away with an initial requirement that patients have an anticipated 72-hour length of stay before the B-Team is called; now, every patient who can benefit from buprenorphine is eligible.
Also, it used to be that only doctors, residents or advanced practice providers could call the team. Now, nurses and social workers can make that request, given that they often recognize opioid use disorder in hospitalized patients sooner than prescribers.
As Dr. Moriates points out, a key factor in the team’s success has been partnering with a community clinic so discharged patients “have a place to land.” He also credits having an in-house community pharmacy in the hospital, to allow discharged patients to fill bridge orders. The B-Team has now received funding from Texas Health and Human Services to help disseminate its model to four other hospitals in the state. That agency is also funding the B-Team’s work on creating an SBIRT (screening, brief intervention and referral to treatment) intervention for hospitalized patients with alcohol use disorder.
In the meantime, the B-Team’s work has not only transformed his center’s treatment protocols and culture, but Dr. Moriates’ own career.
“This has completely changed my hospitalist practice,” he says. While he started practicing without any particular expertise or interest in treating patients with substance use disorders, “it’s an area that’s been very gratifying for me professionally because it’s advancing so quickly. And I know we’re really helping folks who are vulnerable.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the May/June issue of Today’s Hospitalist
Should be started as outpatient by the experienced sub provider with very close follow up (every week or every two weeks) and counseling regarding the diversion. Starting in the hospital is not great idea.