Mary Ann C. Stephens, PhD Vinay Parekh, MD Kenneth Stoller, MD Models for Delivering Medication-Assisted Treatment Panel Discussion

Expanding Capacity and Improving Quality with Collaborative Care: The CoOP Model

Integration models

Single Location

Single Provider Entity:

Multiple Provider Entities:

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Multiple Locations

“Multispecialty Team” “Co-Location” or “Shared Space” Treatment and Prevention in the Opioid Prescription Epidemic

“Collaboration”

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Opioid Treatment Programs (OTPs) • Historically provided methadone, buprenorphine now provided as alternative • Typically function without formal linkage to other parts of the addiction, medical, and mental health treatment system. • Can fill critical need for integrating and coordinating treatment with office-based buprenorphine (OBB) prescribers • Opportunity for role as an Integration Hub March 11, 2016

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Collaborative Care: OBB + OTP OBB Prescribers

OTP

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Office-Based Buprenorphine (OBB) • Waivered physicians can prescribe buprenorphine in primary care or psychiatric settings • Waivers are underutilized • Critical to engage pain treatment providers

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Reluctance to obtain or use buprenorphine waivers OTPs can encourage waivers and support physician practice, by addressing concerns: • Initial assessment: time-consuming

• Induction: initially intimidating • Instability (relapse, diversion, nonadherence): How to intervene to avoid consequences to office, community, patients?

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Collaborative Opioid Prescribing (“CoOP”) model* Purpose: Increase availability, utilization, and effectiveness of OBB through a collaborative care model Allay concerns of OBB providers

*Stoller, K.B., 2015. A collaborative opioid prescribing (CoOP) model linking opioid treatment programs with office-based buprenorphine providers. Addiction Science & Clinical Practice 10, A63 (published abstract). March 11, 2016

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Co-Op Model • OTP provides assessment, induction, counseling, urine testing and relapse management • OBB provides on-going prescription and medication management

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Collaborative Buprenorphine Maintenance OTP is incentivized • Generates patient volume • More prescribers to refer to • Collaboration with medical providers regarding complex co-occurring conditions

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Collaborative Buprenorphine Maintenance OBB prescriber is incentivized • Previously untreated addiction is addressed (e.g. in pain patients)

• Buprenorphine provision with support and ready access to expertise – partner in managing behaviorally challenging cases • Improve medical adherence, morbidity

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Collaborative Buprenorphine Maintenance at our OTP Prior to July 2009: • Discharge if buprenorphine is Rx’d externally 2011-2013: • 81 patients treated under CoOP model 61% Af-Am, 39% Caucasian 64% male, 36% female

• 26 OBB prescribers • 83% of patients were newly inducted

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CoOP: Case Example Adm

Now



54 y.o. woman admitted for opioid, cocaine dependence. HTN, COPD, sarcoid, DJD, disk herniations. Admitted, inducted, IOP counseling. Step:

Bup, Meth Medication location

Med frequency

Counseling intensity

1: Stable OBB

Bup/Nal

PCP script

1 mo Rx

Low

2: Intensive OBB

Bup/Nal

PCP script

1 wk Rx

Intensive

3: Intensive OTP

Bup/Nal

OTP

Daily onsite

Intensive

Methadone

OTP

Daily onsite

Intensive initially

4: Methadone OTP March 11, 2016

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CoOP: Case Example Adm

Now



2 weeks later PCP willing to take over prescribing since service was coordinated.

Step:

Bup, Meth Medication location

Med frequency

Counseling intensity

1: Stable OBB

Bup/Nal

PCP script

1 mo Rx

Low

2: Intensive OBB

Bup/Nal

PCP script

1 wk Rx

Intensive

3: Intensive OTP

Bup/Nal

OTP

Daily onsite

Intensive

Methadone

OTP

Daily onsite

Intensive initially

4: Methadone OTP March 11, 2016

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CoOP: Case Example Adm

Now



Later that month patient stable receiving prescriptions from PCP, and in reduced counseling at OTP.

Step:

Bup, Meth Medication location

Med frequency

Counseling intensity

1: Stable OBB

Bup/Nal

PCP script

1 mo Rx

Low

2: Intensive OBB

Bup/Nal

PCP script

1 wk Rx

Intensive

3: Intensive OTP

Bup/Nal

OTP

Daily onsite

Intensive

Methadone

OTP

Daily onsite

Intensive initially

4: Methadone OTP March 11, 2016

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Relapse Intervention at OTP • Patient subsequently was stepped up and down in counseling/monitoring intensity in response to detected changes in stability and drug use

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CoOP model: Early experience • Successful partnerships formed and maintained • Increased access to MAT  More physicians seeking waivers  Greater use of waivers • Coordination of medical and psychiatric care • Rapid, effective management of relapse

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CoOP model: How to facilitate success 1. Incentivize all parties (“win-win-win”)

2. Involve leadership early 3. Maintain communication 4. Assign single points of contact 5. Encourage progressive reimbursement systems 6. Dispel myths. Co-treatment of MAT and nonMAT patients is NOT problematic March 11, 2016

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