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Tackling opioid treatment in the hospital

Many doctors are still reluctant to initiate life-saving treatment

September 2019
Tackling opioid treatment

IN 2018, Thomas Pineo, DO, medical director of UPMC Pinnacle Community Osteopathic, a hospital in Harrisburg, Pa., began advocating for a system-wide protocol that would put front-line hospitalists in charge of initiating and managing buprenorphine/naloxone (Suboxone) for all inpatients with opioid use disorder and withdrawal. Early this year, that protocol became a reality across all seven UPMC Pinnacle hospitals.

The protocol includes the screening questions now used on patients visiting the ED or admitted, as well as dosing strategies for buprenorphine induction and directions for buprenorphine use in special populations, including those with renal or liver failure. (Copies of the protocol can be downloaded at UPMCPinnacle.com/ProtocolOUD.)

Since the protocol took effect, buprenorphine has proved to be, says Dr. Pineo, “a godsend,” not only for patients struggling with addiction or intolerably high chronic doses, but for clinicians as well.

“Our work with opioid mitigation strategies—particularly buprenorphine—is extremely rewarding.”

Thomas Pineo, DO

~ Thomas Pineo, DO
UPMC Pinnacle Community Osteopathic

With one dose, patients who can be very disruptive become “sane, rational, reasonable,” he notes. “They become much easier for nursing staff and clinicians to deal with, so I feel our work with opioid mitigation strategies—particularly buprenorphine—is extremely rewarding.” He estimates that the hospitalists in his health system initiate buprenorphine a couple of times a week.

But when it came time to craft that protocol, Dr. Pineo says he and a few colleagues pretty much had to figure it out on their own.

“There was no textbook written on how to build an opioid mitigation strategy for our system,” he says. While he interacts regularly with other local champions—the obstetrician who runs a program for addicted pregnant patients, the toxicologist passionate about getting as many doctors certified with X waivers as possible—”there are no comprehensive opioid mitigation guidelines for hospital systems.”

A local effort
When it comes to hospitalists initiating buprenorphine, some national calls to action have been issued. One came this year from the National Academy of Medicine in its “Medications for Opioid Use Disorders Save Lives” report. That report concluded that “withholding or failing to have available” all approved medication classes for opioid use disorder in any care setting—including acute care—”is denying appropriate medical treatment” and “unethical.”

As for state efforts, California Bridge—a program funded by that state’s department of health care services—is giving more than $14 million in grants to dozens of hospitals throughout the state. One of the program’s goals is to get inpatient physicians prescribing buprenorphine. (The inpatient toolkit is online at www.bridgetotreatment.org/inpatient.)

“We need to stop relying on outpatient partners or addiction medicine specialists for initial treatment.”

Melissa Ferguson, MD

~ Melissa Ferguson, MD
Contra Costa Regional Medical Center

A previous California program (Project SHOUT, an acronym for “Support for Hospital Opioid Use Treatment”) was folded into California Bridge. But California is unique as far as state programs, and most hospitalist leaders around the country who are championing medication-assisted treatment on the wards are engaged in what Dr. Pineo calls “a very organic, grassroots, local process.”

Those early adopters are convinced, however, that their efforts will eventually coalesce into regional, statewide and national movements. “I predict that the majority of patients with opioid use disorder or opioid withdrawal will have to receive care from whoever is standing there,” Dr. Pineo says. “That’s going to be their hospitalist.”

Melissa Ferguson, MD, a hospitalist and core family medicine residency faculty member at Contra Costa Regional Medical Center in Martinez, Calif., agrees. Her medical center, which is a county hospital, has a robust outpatient treatment program that inpatient providers can refer to.

But Dr. Ferguson and her hospitalist colleagues have come to realize that “we need to stop relying on outpatient partners or addiction medicine specialists for initial treatment,” she says. “Patients don’t show up at the clinic asking for buprenorphine. Instead, they’re in the ED with an abscess or being admitted for endocarditis or some other complication of their addiction.”

Being able to consult
To initiate inpatient treatment, some hospitalists can turn to pain management and addiction specialists. That’s the case for Cape Coral Hospitalists in Cape Coral, Fla., says Anand Raj Mahadevan, MD, the group owner who’s also a partner in Spectrum Health Partners in central Florida.

“We are not capturing all the patients we need to.”

Amit Vashist, MD

~ Amit Vashist, MD, MBA
Ballad Health

This year, he encouraged his group members to get X waivers to be able to prescribe buprenorphine at discharge. (Doctors don’t need the waiver to prescribe the medication in the hospital.) But in the six months since, two doctors within the four-hospital system his groups serve set up a pain management and addiction medicine service.

“That took away the hospitalists’ incentive to pursue this,” Dr. Mahadevan notes. “Now, we can consult.”

In Syracuse, N.Y., James Leyhane, MD, hospitalist director at Crouse Hospital, says his group likewise has consulted an addiction medicine specialist when patients opt for medication-assisted treatment. The only gap the hospitalists encountered was around weekend prescribing at discharge, with patients sometimes having to stay in the hospital over the weekend.

His planned solution was to have six hospitalists, himself included, obtain X waivers to fill that role. But then the hospital system hired a second addiction medicine specialist.

The ED also stepped up. “Several ED providers obtained waivers, so patients who present after hours, on holidays or over the weekend can be given a prescription for one to three days, enough for them to get into outpatient treatment,” Dr. Leyhane points out. “I tabled the plan for hospitalists to get waivers.”

“Ground zero for opioid addiction”
Amit Vashist, MD, MBA, senior vice president and chief clinical officer for Ballad Health, which has 21 hospitals throughout Virginia and Tennessee, points out that his hospitalists likewise don’t initiate inpatient buprenorphine treatment themselves. Instead, they refer all patients who need medication-assisted treatment to psychiatry.

But Dr. Vashist knows that arrangement isn’t meeting the needs of his patient population.

“We’re in the heart of Appalachia, so we’re at ground zero for opioid addiction,” he says. “We are not capturing all the patients we need to.” Capacity—or rather the lack of—has been the issue, he explains. But by the end of this year, he plans to roll out a two-tiered plan to ensure much broader buprenorphine prescribing.

“Medically-assisted withdrawal without long-term treatment might be fueling the cycle of addiction.”

~ Richard Bottner, PA-C
Dell Seton Medical Center

The first step is targeting the ED. “The emergency room needs to be initiating treatment on a much broader scale. Otherwise, we’ll lose that subset of the population if they’re not admitted,” says Dr. Vashist. “I’m going to argue that we need to capture them as early as we can for treatment.” Once he has ED buy-in, the next step will be training hospitalists to begin treatment on the floors.

He expects resistance from both the ED doctors and the hospitalists—something UPMC Pinnacle’s Dr. Pineo says is realistic. “Any new treatment modality that physicians take on induces a certain level of anxiety,” he says.

Treatment misconceptions
But buprenorphine and opioid addiction bring their own challenges. For one, some doctors believe that buprenorphine prescribing is much more complicated than it really is.

“Buprenorphine is an FDA-approved, well-studied, inexpensive medication that’s been around for almost two decades,” says Richard Bottner, PA-C, a physician assistant hospitalist who’s helping organize a substance use disorder special interest group within the Society of Hospital Medicine. Mr. Bottner also helped launch the buprenorphine prescribing team at Dell Seton Medical Center at The University of Texas at Austin, in partnership with Dell Medical School. Until recently, Mr. Bottner adds, health professionals received little to no formal training about buprenorphine.

“Combine that with the stigma attached to this population and the regulations attached to the medication, and providers have an image of buprenorphine as potentially dangerous and something they should steer clear of,” Mr. Bottner says. (See “Should X waivers go away?”.)

Hospitalists also need to modify what Mr. Bottner says has been the traditional clinical approach to inpatients with opioid withdrawal.

“We assume this is an acute issue that we can treat with additional opioids and get them through the initial crisis, then refer them to outpatient treatment,” Mr. Bottner says. “But 80% of patients to whom we provide only detoxification will be back using illicit opioids within 30 days. Medically-assisted withdrawal without long-term treatment might be fueling the cycle of addiction.”

Moreover, medicine has traditionally viewed addiction as “a behavioral health or psychiatric problem,” he adds. “But the evidence is very clear that that’s not the case, and we need to get to the point of treating it for what it is: a chronic medical illness and a chronic brain disease.”

Developing protocols
At Contra Costa Regional Medical Center, Dr. Ferguson is one of three hospitalists (and several ED physicians) championing the inpatient buprenorphine treatment program there, one made possible by a California Bridge grant earlier this year.

According to Dr. Ferguson, the stigma around addiction has been a big obstacle in moving inpatient treatment forward.

“Doctors always say, ‘I talked to them about their opiate use disorder, but they didn’t want to do anything,’ ” she says. But when patients have diabetes and a diet that doesn’t allow them to control it, she points out, providers don’t stop talking to them about their diet. “We have to push through and continue engaging with them, even if someone has already spoken to them four or five times. This might be the time they actually want to engage.”

She and the other program leaders have developed prescribing protocols for hospital medicine. Hospitalists who feel comfortable prescribing buprenorphine themselves are doing so, while others are still relying on program leaders.

Her next step is to partner with the hospital’s pharmacy department to implement protocols in the EHR and correct misinformation among providers. Future steps include convincing the 25 hospitalists to obtain X waivers, so they can all prescribe buprenorphine at discharge. A longer-term goal is getting both the physicians and the pharmacy comfortable with injectable buprenorphine extended-release (Sublocade).

Planned obsolescence
In Austin, Mr. Bottner’s route to championing buprenorphine induction on the wards started as part of his quality-improvement work for his center’s readmissions committee.

“We found early on that a primary driver of readmissions in our academic urban center was a history of substance use,” he says. In researching potential solutions, Mr. Bottner first obtained an X waiver “to get a better sense of treatment options,” then connected with Hannah Snyder, MD, from California’s Project SHOUT, who’s now a co-principal investigator with California Bridge. It was at that point, he says, that he began advocating to create a buprenorphine prescribing team.

That team—dubbed the B Team, for buprenorphine— debuted last September. That followed a broad educational campaign throughout the medical center with dozens of lectures and meetings, as well as different FAQ sheets on buprenorphine prescribing for nurses and pharmacists. Team members—and those now include doctors, NPs/PAs, nurses, pharmacists, social workers and chaplains—are all volunteers. According to Mr. Bottner, he and the other team members have been connecting with clinicians and advocacy groups around the state. They plan to disseminate the lessons learned from setting up their hospital’s B Team to other facilities throughout Texas.

But he also points out that the program was designed with its own planned obsolescence in mind.

“We’re teaching our clinical teams about opioid addiction and buprenorphine to the extent that, at some point, they won’t need the B Team anymore,” he says. “We don’t consult cardiology for every patient with heart failure or endocrinology for every patient with diabetes. This is the sort of thing we should be able to treat on our own.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Should X waivers go away?

HERE’S ONE of the many big questions around treating opioid use disorder: Should buprenorphine be deregulated?

After all, more than 70,000 Americans in 2017 died from drug overdoses, a figure that Richard Bottner, PA-C, a physician assistant hospitalist at Dell Seton Medical Center at The University of Texas at Austin, cites when calling opioid addiction “the public health crisis of our times.” While buprenorphine/naloxone (Suboxone) can stabilize those patients indefinitely, only 5% of U.S. physicians have an X waiver, which they currently need to do any outpatient prescribing of the drug.

Several states have called for getting rid of the federal X waiver requirement. And this spring, the Mainstreaming Addiction Treatment Act (H.R. 2482) was introduced in the House of Representatives. If passed, the bill—which has garnered several dozen bipartisan cosponsors— would eliminate the need for doctors to obtain a waiver to prescribe buprenorphine.

For doctors, “the course to obtain an X waiver takes eight hours, which is quite a bit of time,” explains Mr. Bottner, who is helping organize a substance use disorder special interest group within the Society of Hospital Medicine. “For physician assistants and nurse practitioners, it’s 24 hours, which is quite a bit more.” That makes obtaining an X waiver a challenge.

But Mr. Bottner also offers this counterpoint: Training programs—including medical and nursing school, NP/ PA and pharmacist training—are only now starting to teach about addiction in general and buprenorphine in particular. “In five years, many more providers will be empowered to prescribe this medication as part of their formal academic training,” he says. “Certainly, more than now. The question is: What do we do in the interim?”

Mr. Bottner also points to what he calls the “psychological challenge” of the X waiver program. “By having it regulated—calling it the ‘X waiver’—and by having to file paperwork with SAMSHA and the DEA, we reinforce the idea that buprenorphine is complex or potentially risky. But the evidence does not support that notion.”

Interestingly, he adds, providers face few fewer barriers to prescribe oxycodone, hydrocodone or morphine. “It’s an odd approach we’ve taken as a country.”

The push for inpatient treatment

ONE OF THE LEADING proponents of hospitalists initiating buprenorphine and other medication-assisted treatments in hospitals isn’t a hospitalist herself.

Family physician Hannah Snyder, MD, is one of two associate directors of the addiction care team at Zuckerberg San Francisco General Hospital and an assistant professor at University of California, San Francisco. But she considers her specialty to be primary care. Several years ago, she headed up Project SHOUT (for Support for Hospital Opioid Use Treatment), a statewide coalition in California that held webinars and issued guidelines that garnered national attention.

“This treatment shouldn’t be siloed or part of some specialized, difficult-to-access care.”

Hannah Snyder, MD

~ Hannah Snyder, MD
Zuckerberg San Francisco General Hospital

Project SHOUT has now been folded into California Bridge, a program distributing more than $14 million in grants to dozens of hospitals around that state. The program’s goal is to train hospitalists, ED doctors and obstetricians in buprenorphine prescribing.

While most hospitalists aren’t yet prescribing medication-assisted treatment, Dr. Snyder believes that at least outdated perceptions around that prescribing are changing.

“More hospitalists are owning this,” she says, “and they realize that this treatment shouldn’t be siloed or part of some specialized, difficult-to-access care. This should just be part of how we treat patients, the same way we give them antibiotics and other life-saving medications.”

Dr. Snyder is also encouraged by how doctors have taken to heart CDC guidance issued in 2016 to reduce opioid prescribing.

“We have to target prescribing so we’re not making more people dependent on opioids,” she says. However, she sees reducing prescriptions as only one of three essential components in fighting opioid addiction.

The second is treatment, which she believes ED physicians and hospitalists should take on. The third is preventing overdoses through naloxone prescribing at discharge.

“They are all really important interventions,” says Dr. Snyder. “They need to be part of an integrated package at every hospital.”

Published in the September 2019 issue of Today’s Hospitalist.

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