Project ECHO: Extending Opioid Treatment Statewide - Minnesota Hospital Association
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Project ECHO: Extending Opioid
Treatment Statewide
Brian Grahan, M.D., Ph.D.
Friday, Jan. 11, 2019
4:20 – 5:20 p.m.
Northland Ballroom
Brian Grahan, M.D., Ph.D. Dr. Brian Grahan was introduced to addiction medicine by happenstance during his research on decision making and health outcomes during his M.D.-Ph.D. program at the University of Wisconsin. Once he learned to see it, he noticed it everywhere but rarely addressed. Yet, when treated appropriately by healthcare providers, people had outcomes better than diabetes and high blood pressure with immense impact on individuals, families and their communities. He never turned back. He moved north to the University of Minnesota’s combined residency in internal medicine and pediatrics to learn how to care for the sickest people across the life course, completed a chief residency in quality and patient safety at the Minneapolis VA Healthcare System to continue building organizational change skills, then did the Minnesota Addiction Medicine Fellowship. He now practices as the medical director of office-based addiction medicine, a primary care provider in the Coordinated Care Center, and director of the Integrated Opioid and Addiction Care ECHO program at Hennepin Healthcare in Minneapolis, Minnesota.
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Project ECHO: Expanding Opioid
Treatment Statewide
Minnesota Hospital Association Winter Trustee Meeting
January 11, 2019
11/08/2018
Disclosures
• I have no financial conflicts of interest.
• I will not be discussing off-label use of medications
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Learner objectives
1. Describe status of opioid epidemic in Minnesota
2. Understand background and implications of DHS opioid report card
3. Appropriately refer patients to addiction medicine services
4. Access Project ECHO sessions as a forum to learn about and discuss complicated opioid-related
patient cases
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Adjusted difference in physical health scores in chronic
opioid users versus non-opioid users
Dose of opioids
in morphine
equivalents
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Sullivan Dillie K, et al. J Am Board Fam Med. 2008;21:108–117.
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Impact of chronic opioid use and opioid agonist
maintenance therapy
Persistent use resets
Normal variation. Your
homeostasis. Other behaviors
body’s opioid level
may become secondary, and drug
increases with exercise,
use may become compulsive.
friendship, sex, food. Treatment goals: Studies suggest >85% of
Withdrawal develops, and goal of
Also rises in response to
use gradually shifts from “get1. No opioid cravings people relapse without
acute trauma to 2. No illicit opioid use agonist medication. A few
high” to “feel less bad.”
compensate for pain. 3. Feel normal people do well;
Level decreases with 4. Safe dose, no diversion unfortunately, we poorly
depression, etc. predict who, how, or when
Buprenorphine/Methadone to taper successfully.
Normal
baseline
?
In the predisposed Some patients expect Planned tapers should
person, exposure to to taper eventually. include close support, and
? recommendation to
an opioid results in Recovery of function is
an outsized uncertain. continue buprenorphine if
? destabilizing symptoms
response that
dwarfs other stimuli. arise.
At the new baseline level, a person’s own opioid system is
suppressed. They’re less able to cope with new painful
stimuli, including withdrawal.
Created by Brian Grahan, MD, PhD on 4/1/18
Time Hennepin Healthcare Opioid & Addictions Care Project ECHO
Conceptual framework: Addictive behaviors
Stage of Addiction Shifting Drivers Resulting from Neuroadaptations
Binge and intoxication Feeling euphoric Feeling good Escaping dysphoria
Withdrawal and Feeling reduced Feeling depressed, anxious,
Feeling reduced excitement
negative affect energy restless
Preoccupation and Obsessing and planning to get
Looking forward Desiring drug
anticipation drug
Behavioral Changes
Voluntary action Sometimes taking when not intending Impulsive action
Abstinence Sometimes having trouble stopping Relapse
Constrained drug taking Sometimes taking more than intended Compulsive consumption
Volkow ND et al. N Engl J Med 2016;374:363-371
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What distinguishes addiction from chronic opioid use?
• Impaired control
• Social impairment
• Risky use
• “Physical dependence”
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Volkow ND et al. NEJM 2016;374:363-371
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Scope of the Epidemic
16% primary care Medicaid patients on chronic opioids
MN DHS 2016 1.3 M patient years >600,000 opioid Rx
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Child protective services involvement
• Reasons for (CPS) involvement
• #1: parent with substance use disorder
• #2: prenatal opioid exposure
• Foster care due to parental drug use
• 1,200 in 2012 2,800 in 2016
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Geography of the problem
• Highest volume of misuse and related deaths are in the seven-county metro area
• Community prevalence highest in rural areas
• Cass, Clearwater, and Mahnomen Counties have the highest rates of youth prescription drug
misuse
• Mahnomen and Cass have the highest rates of drug poisoning deaths; Clearwater has the fifth
highest rate
• Cass, Clearwater, and Mahnomen Counties in the top ten highest counties for percentage of
treatment admissions involving opioids as the primary substance of abuse
• Prescriptions filled per 100 population were higher in Cass (189), Clearwater (194) and Mahnomen
(183) as compared to metro/urban Hennepin (140) or Ramsey (138)
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Geography of the problem
• Density and number of addiction specialists and treatment options highest
in seven-county metro area
• Scope of problem statewide
• Opioid use disorder can be diagnosed and treated in usual clinic settings
• People across MN already innovating
• How to get a handle on the problem?
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Where to start?
Many communities & organizations already doing
the work!
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DHS Opioid Sentinel Measures
• Acute prescribing rates
• Acute prescribing doses
• Stopping acute opioids early
• Chronic prescribing rates
• High dose chronic prescribing
• Mixing high dose chronic opioids and benzos
• Prescribing to doctor shoppers
Example
First report early 2019
Only DHS and you will
see it
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Opioid Prescribing Work Group (OPWG) Mandate
• Generate recommendations for opioid prescribing based
on current literature
• Analyze 2016 MN Medicaid opioid prescribing data
• Develop sentinel measures for opioid prescribing
• Provide feedback on sentinel measures to Minnesota
providers
• Quality improvement for outlying prescribers
• Educational campaign
Not OPWG Goals:
• Not a comprehensive opioid strategy for the state
• Not a comprehensive pain strategy for the state
• Punish or hinder providers working in good faith
• Dis-incentivize care of Medicaid patients
• Worsen the care of patients in acute pain
• Make chronic opioid, chronic pain patients unstable
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Best practices for patients on chronic opioids
• Avoid sedatives (benzo, alcohol)
• Obtain routine urine drug tests (universal precaution)
• Frequently re-evaluate indication and consider taper
• Focus on functional outcomes
• Assess for aberrant behavior
• Check PMP
• Ask about “Bad day” use
• Screen for opioid use disorder
• Prescribe naloxone
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Managing Problematic Opioid Use
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Screening strategies
• Review indication for all patients on chronic opioids
• Taper opioids when indication unclear or high dose (per DHS/ICSI thresholds)
• Consider Pain Committee review for challenging patients
• Diagnosis of OUD often emerges from series of unexpected or inexplicable behaviors
• Universal precautions when prescribing controlled substances
• Intermittent urine drug screens
• Check PMP
• When help advertised in familiar setting, patients sometimes present seeking it
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Systems of care
• Establish clinic-wide expectations
• DHS & ICSI standards
• DHS provider-specific opioid reports coming in 2019!
• Promote an internal pain or controlled substance committee as resource for difficult case
discussions
• Encourage pharmacy and lab partnerships
• Leverage statewide expert case consultation for difficult patients with possible addiction
• ECHO: Wednesdays & Thursdays 12:15-1:15
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Managing Opioid Use Disorder
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Managing Opioid Use Disorder
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Managing opioid use disorder (OUD)
• Build clinic capacity to recognize and treat OUD with buprenorphine
• Get at least 2 waivered prescribers
• Develop systems of care – consider nurse care manager
• Connect with a network of mentors & colleagues
• Develop referral relationships to treatment programs and higher levels
of medical care (specialty OBAT clinics or OTPs)
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Addiction Care Continuum within Hennepin Healthcare
• Specialty Office- • OBAT clinic
based Addiction
Treatment (OBAT) • Primary care
• Consultations • Chronic disease
management
• Opioid Treatment
Program (OTP)
• LADC for treatment
program coordination
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Addiction Care Continuum across Minnesota?
• Specialty Office- • OBAT clinic
based Addiction
Treatment (OBAT) • Primary care
• Consultations • Chronic disease
management
• Opioid Treatment
Program (OTP)
• LADC for treatment
program coordination
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How does Project ECHO work?
“Moving knowledge, not patients”
How does Project ECHO work?
“Moving knowledge, not patients”
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How does Project ECHO work?
• Complex conditions
• Guided practice over time
• Brief “didactics”
• De-identified case review
“Workforce Multiplier”
Integrated Opioid & Addiction Care
• Thursdays 12:15 – 1:15p
• Case-based interactive learning series via Zoom videoconference
• No travel, no fees, participate via plug-and-play videoconference
• AMA PRA Category 1 CreditsTM per session
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Why Project ECHO?
Is Project ECHO telemedicine?
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Hub
Team
Source: Michelle Iandiorio, MD, Project ECHO New Mexico
In the end, it’s always all about the people…
• ECHO works by leveraging personal relationships
• Joy of work
• Adapting new innovations to clinical practice
• Sharing best practices for each clinic setting
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191/2/2019
Buprenorphine Boot Camp
• 1:00p on February 21st – 2:00p on February 22nd
• Goal: To support implementation of clinical teams’ interest in prescribing buprenorphine for opioid
addiction in their clinics
• Recommend each clinic bring at least a team of 2-3 prescribers, a nurse, and a clinic manager
• $159/person
• No fee for providers getting waivered to prescribe buprenorphine for OUD
• Crowne Plaza Minneapolis West in Plymouth, MN
• Hosted by Hennepin Healthcare and MN Hospital Association
• Supported by ECHO partners: CHI-St Gabriel’s in Little Falls and Wayside Recovery Center
• HCMC.Opioid.ECHO@hcmed.org or (612) 873-3060 for details and registration
1/2/2019
Brian.Grahan@hcmed.org
HCMC.Opioid.ECHO@hcmed.org
www.HennepinHealthcare.org/echo
Office: 612-873-3060
Questions?
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