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bUPrenorphine: A Real Rural Experience from Michigan’s Upper Peninsula

Explore the real experience of using BUPrenorphine in Michigan's rural Upper Peninsula region, where the distance and population density present unique challenges.

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bUPrenorphine: A Real Rural Experience from Michigan’s Upper Peninsula

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  1. Shawn K. Hatch, ACSW, LMSW, CCS, CAADC Marquette General Health System bUPrenorphine: A Real Rural Experience from Michigan’s Upper Peninsula

  2. The Upper Peninsula (U.P.) • Maximum east-west distance – 320 miles • Maximum north-south distance – 125 miles • 1700 miles of continuous shoreline with the Great Lakes • 4,300 inland lakes and 12,000 miles of streams

  3. Population Density: 19 people per sq. mile

  4. Population by County: 2010 *U. S. Census Bureau: 2010 Population of UP Counties 2,156 36,628 6,780 67,077 8,860 7,028 16,427 9,601 38,520 11,817 11,113 8,485 26,168 37,069 24,029

  5. More about the UP • Total population: 311,258 • The UP holds 30% of the total land mass and 3% of the state population. • Three largest cities in the UP* • Marquette 21,000 (Marquette County) • Sault Ste. Marie 14,000 (Chippewa County) • Escanaba 12,000 (Delta County) • * 2010 U.S. Census

  6. And sometimes it snows . . . .

  7. County Health Rankings Morbidity and Mortality

  8. County Health Rankings Healthy Behavior Clinical Care Social & Economic Physical Environment

  9. The UP is special but not unique • The UP has a growing problem with opiate and prescription drug abuse.

  10. Addiction in the UP National Michigan UP Alc. dep. or abuse in past year 7.53 7.79 8.05 Illicit drug dep or abuse in past year 2.82 2.88 3.07 Dep. on or abuse of any illicit drug 9.07 9.41 10.00 or alcohol in past year Nonmedical use of pain relievers in past year among person aged 12 or older National MichiganUP 5.00 5.63 5.29 MDCH, Mental Health & Substance Abuse Administration Bureau of Substance Abuse & Addiction Services State & Substate Estimates of Substance Use in Michigan 2006-2008 National Surveys on Drug Use and Health

  11. Options for Treatment for Opiate Dependency in the UP • Traditional outpatient and residential treatment programs • Methadone . . . not available in the UP • Green Bay, WI – 175 miles • Muskegon, MI – 440 miles • Buprenorphine • 4 physicians accepting new patients

  12. Overview of Buprenorphine and FAQ

  13. What is buprenorphine? • Medication approved for the OP treatment of opiate dependence in 2000 (Drug Abuse Treatment Act of 2000). • Set physician qualifications for prescribing. • FDA approved Suboxone/Subutex in 2002. • Partial Opioid Agonist • Ceiling effect • Withdrawal & Craving

  14. What is buprenorphine? • Suboxone • 8 mg buprenorphine/2 mg naloxone • Subutex • 8 mg buprenorphine • Primarily for pregnancy

  15. But I’ve heard that you can abuse it! • Multiple reports of addicts snorting or using IV. • Amount of naloxone may not be enough for some individuals. • This is an abusable drug – like most, can be used for good or evil.

  16. How come all doctors don’t prescribe? • Prescribers must go through special training and are issued a separate DEA number. • Prescribers are limited to 30 patients for the first year. • Can apply for a waiver and treat up to 100 after the first year. • Many prescribers want this population out of their office . . . . • Prescribers still have limited knowledge of addiction.

  17. Can you get high from it? • Yes • It isn’t the “drug of choice” but it is (significantly) better than nothing • The “high” experience • Expectancy • Relief from sick to not sick • Great to have on hand in case addict can’t score • Selling/trading for full agonist

  18. Pregnancy • Methadone is currently the “standard of care” for the pregnant opiate addict. • ACOG: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes, 2010 • Lower NAS scores for the Subutex babies • 10.69 versus 12.5 • Shorter LOS • 8.4 versus 15.7 • Less than 50% of Subutex babies requiring treatment versus 73% of methadone babies

  19. Drug Addicted Babies at MGHS 2006 14 2007 23 2008 17 2009 23 2010 45

  20. Isn’t it just switching one drug for another? • Yes . . . . and no • Making the leap

  21. The “Open Door” Experience • June of 2007 – MGHS accepts first patient • Brief phone screen • Quickly overwhelmed • Swamped with phone calls • High “hassle factor” • Reports of “lost” or “stolen” meds • Requests for early refills • Refill requests . . . from jail • High volume of drop-outs and non-compliance • April of 2008 – Discontinued admissions • 10 months and 29 patients

  22. Maybe we should just give up . . • No denying how desperately this service was needed. • At this point, only one other physician prescribing in the UP. • We had a handful of patients who were doing well for the first time in their lives. • This posed an interesting and challenging question: How do we expand this classification of patients?

  23. Re-Grouping • Prescribing physician left our organization • Dr. John Lehtinen agrees to prescribe. • Road trip

  24. Questions on the table: • How do we manage a limited resource? • How do we make this service available to the best treatment candidates? • How do we manage the “hassle factor” and prevent burning out our staff and physician? • How do we maintain our integrity and credibility with local agencies, treatment providers, law enforcement, and most importantly, our patients?

  25. The Application and Review Committee • Slowing down the process and looking for the best matches for the medication. • Rationale for the application: • Completing and mailing the application would require effort. • The application would allow us a better opportunity to screen applicants and potentially fill the limited treatment slots with those in the best position to benefit from buprenorphine.

  26. The Application and Score Sheet • Items from criteria in TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Dependence: • History of treatment completion/compliance • Not currently abusing benzos, sedative-hypnotics, or barbiturates • Not currently abusing alcohol • Supportive living environment • Supports for recovery

  27. The Application and Score Sheet • Dependence is limited to opiates • Employed • No medical contraindications • Indicated agreement to abide by rules and expectations.

  28. We added: • Already being treated with Suboxone and successful • Active in substance abuse treatment • Treatment goal of abstinence • Has resources to pay for treatment and medication • Not in collections with us • “Clean” MAPS • Application is complete

  29. Application Packet: • Buprenorphine screening questionnaire • MGHS Personal Data form • Releases of Information to the PCP and current substance abuse professionals, as applicable • Treatment contract* • Patient and family information about buprenorphine • Summary of substance use

  30. *Treatment Contract • Program Requirements: • Attendance at all scheduled appointments • Attendance at a substance abuse program • ROI’s to all physicians and counselors/therapists • Abstinence from alcohol and drugs

  31. *Treatment Contract • Patient Responsibilities: • Store medication properly • Take as prescribed • Pill counts • Drug testing • Notify office if medication lost or stolen • Notify of relapse • Payment for services

  32. The Process • Application is sent to caller. • Returned applications are “scored” • Review by Committee • Higher scoring applicants are contacted to schedule appointment with physician and for induction; assuming no medical contraindications. • The score sheet – no magic number or total score for automatic admission

  33. All other applicants: • Receive letter with specific treatment recommendations and an invitation to meet with addiction physician in consideration of other treatment options. • Receive instructions regarding how to access services for his/her circumstances, i.e., location, treatment history, funding source, etc. • Encouraged to contact us for second review if treatment recommendations are followed through.

  34. The Review Committee • Prescribing Physician • Director of Clinical Services • Clinical Supervisor • Clinician

  35. The Committee • Provides forum to review program policy, discuss clinical challenges, and advocate for candidates. • Takes “heat” away from prescribing physician.

  36. The Results • Between August of 2009 and March of 2011 more than 350 applications were distributed.

  37. Sent applications: County • Marquette 46% • Delta 19% • Dickinson 12% • Baraga 5% • Houghton 4% • Menominee 4% • Schoolcraft 3% • Iron 2% • Chippewa 1% • Ontonagon 1% • Gogebic n=2 • Luce n=1 • Mackinac n=1 • Alger n=2 • Wisconsin n=2 • Lower Pen. n=1

  38. Sent Applications • 50/50 split between males/females • Average distribution rate has been 18 per month • Nearly half (170) of the 350 applications were completed and returned to the Review Committee • 28% of those who have returned applications have been admitted for buprenorphine treatment.

  39. Returned Applications • Average age 29.8 • Age: • 17 1% • 18-30 61% • 31-40 28% • 41-50 8% • 51-65 1% • Race • 91% Caucasian • 9% Native American • Sex • Male 46% • Female 54%

  40. The “Open Door” • June 2007 – April 2008 (10 months) • 29 patients admitted • 22 of original 29 were discharged • 20 of the 22 were discharged by October of 2009, however, nearly half were gone within the first 4 months of treatment • 13 dropped out • 7 discharged “at staff request” • 2 completed

  41. The Application Admissions • August 2009 – March 2011 (19 months) • 48 patients admitted • 7 discharges • 5 dropped out • 2 discharged “at staff request” • Retention rate went from 24% to 85% • Significant reduction in the “hassle factor” • Able to more than double admissions without additional staff resources • Currently have 76 patients enrolled in the program.

  42. The Adventure Continues • Pregnancy • The only exception to the application process • The application process would delay treatment • Acknowledgement that our focus has shifted to treat the pregnant addict and provide the best possible start for the baby. • Limited window to engage the patient in treatment and recovery.

  43. Challenges: • Non-compliance with counseling • Late entry into pre-natal care and treatment • Shame • Use of other drugs/continued drug use • Poor support system • Poverty • Distance from physician (from all over UP) • “Hostage” until birth • Case coordination between OB/NICU and prescribing physician • Pregnancy to access program.

  44. Noteworthy . . . • High volume of pregnant addicts seeking treatment with buprenorphine • 43 since December of 2010; 40 pregnant at admission • The return of the “hassle factor” • Incentive to comply • About 25% compliance but improving. • Better outcomes from NICU • Shorter LOS and less severe withdrawal

  45. The Lessons: • How significant problem of opiate addiction is in the UP • Buprenorphine isn’t for everyone • The application process is an effective way to manage a valuable and limited treatment resource • Support group didn’t fly. • How long should someone be on buprenorphine? A controversial and individualized question.

  46. More Lessons: • Counseling need to start before the buprenorphine and the longer the better • We need to continually “take our own inventory” regarding attitudes, beliefs, biases, regarding buprenorphine treatment and patients. • We still have much to learn . . . . • More challenging and stimulating opportunities lie ahead . . . .

  47. Questions: Shawn K. Hatch, ACSW, LMSW, CCS, CAADC Director of Clinical Services, Behavioral Health Marquette General Health System Shawn.Hatch@mghs.org (906) 225-3214

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