February 06, 2018, 02:13 pm Chris Crawford — A new feature in Annals of Family Medicine examines innovations in primary care. For the January/February 2018 issue of the journal, the feature highlighted the success a rural health clinic in Scappoose, Ore., and an associated federally qualified health center (FQHC) in Portland are having using an interdisciplinary model to care for patients with opioid use disorder (OUD). Both clinics are part of the family medicine department at Oregon Health & Science University (OHSU) in Portland.
Many primary care clinics have developed treatment models for OUD, but few have done what this group has in integrating comprehensive behavioral health strategies to improve outcomes, according to the Annals article.
"Although medication-assisted treatment (MAT) models that emphasize medications may be effective, failure to offer robust psychosocial services can yield suboptimal outcomes, especially in complex patients," the authors said. "We implemented a behavioral health-focused model for MAT to expand access, better engage patients in treatment and improve health outcomes.
"This was built on concepts of harm reduction and improvement in functioning, emphasizing behavioral health counseling in addition to medications."
Corresponding author Rebecca Cantone, M.D., assistant professor at OHSU Family Medicine at Scappoose, told AAFP News that although some patients do well with medication or counseling alone, her team thought treatment would be more successful if they combined multiple elements: managing the physical addiction, cravings and withdrawal; working through the addiction itself; and managing the issues and/or psychosocial factors that led to the addiction and/or substance use in the first place.
MAT, as the name implies, is assisting the treatment, she noted. "It is not the actual treatment, nor was it designed to be."
Created by Cantone's colleagues Nicholas Gideonse, M.D., and Joan Fleishman, Psy.D., the treatment model was adapted from a tier model used by the University of Massachusetts. As founding medical director of the Scappoose clinic, Cantone helped adapt the model for use in the rural clinic. Brian Garvey, M.D., M.P.H., is the current medical director of the Scappoose MAT program.
Cantone said the biggest obstacles the team faced when implementing the new model were hiring enough staff to support it and getting everyone trained.
Both facilities are staffed by family physicians, nurse practitioners, registered nurses, physician assistants and a medical director, and residents and medical students regularly rotate through each site.
It's important, Cantone noted, to have a dedicated behavioral health professional on site because most medical staff aren't as skilled as this type of professional in providing addiction counseling and relapse prevention strategies.
In Oregon, physicians, nurse practitioners and physician assistants can train to provide buprenorphine-containing medications. The number of these trained medical professionals at both OHSU family medicine facilities continues to grow, she said.
"Collaborating with local substance use treatment centers, detox centers and mental health is also incredibly important to have the backup and next steps for patients who are not doing well," Cantone said.
During the initial phase of treatment, the behavioral health professional addresses substance use history, family dynamics, social situation and readiness for engagement in treatment.
"The behavioral health clinicians have specific interest and experience working with patients with substance use and are trained in trauma-informed care, motivational interviewing, cognitive behavioral therapy and relapse prevention," Cantone said.
The behavioral health personnel use American Society of Addiction Medicine criteria to recommend levels of care and ensure that outpatient MAT is a safe and appropriate level of treatment, she added. They have frequent contact with patients using a dual-diagnosis approach that addresses mental health and psychosocial issues, as well as the substance use disorder.
Cantone said the two facilities try to select patients for the program who can engage in regular visits but who do not require the rigid structure of daily methadone dosing. Patients who have already tried or who have contraindications to methadone are appropriate candidates.
"The patient must be interested in acknowledging that opioid use disorder exists, and not solely that they have pain and just got cut off," she said. "People who acknowledge, or are open to discussing, the issue of addiction in their life are the best candidates."
First, patients have a combined appointment with a behavioral health professional and the registered nurse to review medications and medical risks and to assess their level of motivation. They complete an initial behavioral health screening and then receive a combined recommendation to either start or not start treatment; this recommendation may include other treatment options.
"If recommended, patients get a medical provider treatment appointment to review medical risks and benefits, update any necessary labs, and decide on medication timing and dosing," Cantone said.
All accepted patients start out at Tier 1 with very intensive visits that occur about twice a week. If they have any relapses and/or are struggling, they continue in this maximum support tier.
As the MAT dose stabilizes with no opioid use, patients progress to Tier 2 and Tier 3, progressively having fewer visits with the medical team.
Patients who have been stable on a reasonable medication dose (which varies depending on the provider, but ideally is 8-12 mg per day), who also have engaged in addiction counseling with the behavioral health staff and/or an outside agency, and who have ongoing stabilization with a support system/job/life can progress to Tier 4, said Cantone.
"Many patients will stay in this tier for quite some time, depending on ongoing life circumstances and relapse risk, as determined by the patient, medical provider and behavioral health provider," she said. "Patients and any provider can choose to escalate care or taper it off, if desired.
"Having a tier system that dictates the minimum number of visits while allowing providers to escalate that at any time is (key) to our success," Cantone said.
For family physicians who may wish to use this model to treat OUD, Cantone emphasized that allowing behavioral health professionals to handle the psychology and treatment of addiction makes things easier for physicians.
"It only works if the behavioral health and medical providers have an ongoing relationship with open communication to maintain a safe and effective treatment plan," she said.
Cantone said her team is available to help interested family physicians by sharing materials and answering questions.
"You'll need to start by finding a skilled and motivated behavioral health provider who is excited and competent in addiction medicine treatment, as well as a program medical director to help with the ongoing coordination of care for both patients and staff," she said.
OHSU Family Medicine at Scappoose started developing its model with a large executive team that envisioned a plan at the clinic level, before prescribing clinicians or practicing behavioral health clinicians were involved, to ensure all supports were in place before hiring staff or redesigning the program.
"Most of all, I recommend medical providers strongly consider providing medication-assisted treatment in some context to help with the continuing problem of opioid use disorder in the United States," Cantone said. "We are training medical students and family medicine residents, as well, to help build a future workforce more comfortable with managing addiction."