Changing Pathways: Improving outcomes and saving lives of individuals with Opioid Use - PowerPoint Presentation

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2. Changing Pathways: Improving outcomes and saving lives of individuals with Opioid Use DisorderJ. Craig Allen, MD, FASAMCarrie Bourdon, LCSW Sandrine Pirard, MD, PhD, MPH *Nothing to Disclose

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4. Agenda1Scope of Opioid Overdose Crisis2Medications for Opioid Use Disorder (MOUD)3Best Practice Considerations: Changing Pathways4Overview of the Changing Pathways Pilot5Implementation of the Changing Pathways Pilot6Outcomes: All Providers7Outcomes: Rushford8Lessons Learned9 Resources10 Questions/Comments?

5. ChapterScope of Opioid Overdose Crisis

6. Scope of Opioid Overdose CrisisUnintentional drug overdose (OD) is the leading cause of death for Americans under the age of 50More than four times as many people died from OD than from homicide in the first month of 202196,779 drug overdose deaths were reported from March 2020 to March 2021OD death totals during this period are 36.1% higher than the previous annual high from December 2018 to December 2019 (71,130 deaths)Preliminary reports indicate the number of drug overdose deaths in America increased 29.6% in 2020Drug Overdose Death Statistics [2022]: Opioids, Fentanyl & More (drugabusestatistics.org)

7. Drug overdose death rate among Black men in the U.S. more than tripled between 2015 and 2020 | Pew Research Center

8. ChapterMedications for Opioid Use Disorder (MOUD)

9. Medications for OUD (MOUD)MOUD along with counseling, & support from family and friends is the most effective treatment for OUDThree FDA-approved medications for OUD:Methadone, buprenorphine, & naltrexoneAll three reduce/eliminate cravings, blunt/block effects of illicit opioids, and support long term recoveryMethadone & buprenorphine reduce/eliminate withdrawal symptomsNOT trading one addiction for another; physical dependence vs. addiction

10. Opioid Agonists and AntagonistModified from: Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.

11. MOUD Risks/BenefitsIncrease treatment retentionReduce risk of return to use Reduce opioid-related deathsImprove overall healthImprove social functioning including employment Reduce the risks of infectious-disease transmissionReduce criminal activityImprove birth outcomes in pregnant women with opioid use disorder

12. MOUD Risks/BenefitsPotential medical risks (medical comorbidities, drug-drug interactions)Misuse potential Diversion OD risks (methadone vs. buprenorphine vs. naltrexone)

13. ChapterBest Practice Considerations:Changing Pathways

14. Changing Pathways: Background and ContextOpioid overdoses continue to increaseMembers admitting to inpatient settings are high riskTraditional withdrawal management is associated with poor outcomes and used alone can increase the risk for overdoseMOUD is effective treatment for OUD

15. Inpatient Psychiatric (IPF) Hospitalizations & OUD

16. Detoxification vs. Maintenance 1-year retention: 75% (maintenance) vs. 0% (detox)Deaths: 4 (detox) vs. 0 (maintenance)Lancet, 2003; 361:662-8

17. Evidence-based Practice: MOUDOpioid agonist therapy (OAT) is associated with lower relapse risk and lower monthly expendituresJ Subst Abuse Treat. 2015; 57: 75–80

18. ChapterOverview of the Changing Pathways Pilot

19. The Changing Pathways ModelTypical PathwayImproved Pathway

20. Three Essential Components:

21. Changing Pathways Providers

22. ChapterImplementation of The Changing Pathways Pilot

23. Multiple Touchpoints For MOUD EducationClient with OUDpresents to triageClient with OUDundergoes intakeClient with OUD is givena biopsychosocialassessmentClient with OUDcontinues regularinteraction with nurses,clinicians and counselorsthroughout inpatient stayInitial MAT Education isprovided by the nurseperforming intakePhysician provides MATEducation (including discussion of the risksand benefits of MAT)with the clientClinician provides MATEducation to clientProvider staff continueto discuss MAT withclient, understandingand helping to addressany barriers to choosingthis pathwayAll points at which MATEducation was performed arenoted in the client’s chart anddocumented on the Higher Levelof Care Discharge Form

24. Implementation Steps

25. Implementation Continued

26. Implementation Continued

27. ChapterOutcomes: All Pilot Providers

28. Average Induction Rates: 1st Half of Pilot vs 2nd HalfInterCommunity: 15.9% to 34.6%, highest peak in October 2019 at 48.8% (61/125 discharges)Rushford: 19.7% to 27.5%, highest peak in March 2020 at 34.5% (19/55 discharges)SCADD: 36.3% to 39.9%, highest peak in July 2020 at 55.2% (32/58 discharges)SFH: 39.4% to 22.9%, highest peak in June 2020 at 47.4% (9/16 discharges)Hartford Hospital: Too early in the pilot for comparison dataPilot providers have adopted the model demonstrated by increasing MOUD induction rates

29. Increase in Connection to MOUD Post Discharge

30. 2020 Rate of Connection to MOUD by Medication 65.80%76.80%58.80%72.20%18.00%35.30%7.70%29.00%4.92%15.50%5.90%9.80%InterCommunityRushfordSt. Francis Hospital &Medical CenterSoutheastern Councilon AlcoholismMethadoneBuprenorphineNaltrexone

31. MOUD Adherence RateInduction was associated with much higher 90-day MOUD adherence rates *Adherence means using MOUD at least 80% of days for the three months following discharge

32. Reduction in OverdosesIndividuals who engaged in Changing Pathways in 2020 and remained MOUD adherent for 90 days following discharge, experienced a 74.4% reduction in their rate of overdose, from 8.2% of members having an overdose in the 90 days before admission to 2.1% of members having an overdose during the 90 days following discharge.Individuals who were non-adherent only saw a 15.6% reduction (from 7.7% to 6.5%, respectively). *Adherence means using MOUD at least 80% of days for the three months following discharge

33. Additional Findings…Those members who meet the 80% MOUD adherence threshold saw a significant decrease in:The number of BH ED episodes (54.2% reduction)The number of repeat withdrawal management episodes (55.8% reduction)The number of inpatient days (39.7% reduction) After discharging from withdrawal management careThose members who were non-adherent to MOUD saw a significant increase in:The number of inpatient days (26.6% increase)The number of repeat withdrawal management episodes (9.4% increase)After discharging from withdrawal management care*There was a non-significant decrease in the number of BH ED Episodes (6.9% reduction) for members who were non-adherent

34. ChapterOutcomes: Rushford

35. Rushford MOUD Education Rates*Due to a claims lag, reporting for this metric runs through July 2021. MOUD education rates for Hartford Hospital are not available given their start date of the pilot Total OUD DischargesTotal Inductions% of Discharges Inducted (B/A)# of Discharges Receiving MOUD Education% of Discharges Receiving Education (D/A)# of Inducted Receiving MOUD Education% of Inductions Receiving Education (F/B)January 2020591525.4%5593.2%1493.3%February 2020521325.0%5096.2%13100.0%March 2020411434.1%3585.4%14100.0%April 202035822.9%3291.4%8100.0%May 2020411229.3%3790.2%1191.7%June 20203738.1%3389.2%3100.0%July 202045920.0%4497.8%888.9%August 2020451022.2%45100.0%10100.0%September 202058915.5%5594.8%9100.0%October 202050816.0%4998.0%8100.0%November 2020491428.6%4795.9%14100.0%December 202043920.9%4195.3%9100.0%January 2021651116.9%6295.4%11100.0%February 20214624.3%4597.8%2100.0%March 2021481225.0%4797.9%1191.7%April 2021401025.0%40100.0%10100.0%May 20215758.8%5189.5%5100.0%June 20213925.1%3794.9%2100.0%July 202137718.9%3697.3%7100.0%

36. Reduction in Readmissions and AMA Rates: RushfordInpatient Dashboard – Medicaid Adults (18+)Induction vs. DetoxificationData Last Updated: 2/15/2022Dashboard data refreshes on a weekly basisEffective Discharge Date1/1/202112/31/2021ProviderRushford Center Inc.Opiod DiagYesEligibilityNon-DualsMOUD 15 Days Prior to AdmissionN/A(All)Primary Diagnosis*XDischarge VolumeInductionDetoxification18.7% (139)81.3% (604)InductionDetoxification5.0% (7)39.9% (241)InductionDetoxificationInductionDetoxification2.2% (3)7.1% (43)12.2% (17)24.2% (146)Against Medical Advice (AMA) Rate30-Day Readmission Rates7-Day Readmission Rates

37. ChapterLessons Learned

38. Lessons Learned: Provider PerspectiveAn integral element rooted in the success of the pilot has been rigorous MOUD education practices provided during three various touchpoints throughout treatmentA cultural shift among all staff members is necessary in order to provide effective MOUD educationThe development of warm hand-off relationships solidifies discharge plans, eliminates access barriers, and provides a smooth transfer processOperational challenges were inevitable, impacted by staff turnover, changes in EHR systems, and COVID-19. Regular training, and monitoring of policies and procedures helped to mitigate when possibleAs a person with lived experience, the peer component of the pilot serves as a valuable resource for meeting members where they are at, improving engagement, and assisting with connections to aftercare

39. ChapterResources

40. Resources for Finding Treatment ProvidersNIAAA Alcohol Treatment Navigator: https://alcoholtreatment.niaaa.nih.gov/ATLAS Treatment Locator: https://www.treatmentatlas.org/SAMHSA MAT: https://www.samhsa.gov/medication-assisted-treatmentSAMHSA Buprenorphine Treatment Practitioner Locator: https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locatorSAMHSA Behavioral Health Treatment Locator: https://www.findtreatment.samhsa.gov/

41. Clinical Toolshttps://pcssnow.org/resources/clinical-tools/:Patient/family informationIntakeTreatment AgreementsInductionDrug accountability formsOngoing TreatmentHow to prepare for DEA inspection

42. Clinical ToolsSUD & COVID:COVID-19 Coronavirus (asam.org)ED Buprenorphine Induction:ED-Initiated Buprenorphine < ED-Initiated Buprenorphine (yale.edu)‎BUP Initiation on the App Store (apple.com)Buprenorphine Initiation app - Apps on Google PlayEmergency Department Initiated Buprenorphine For Opioid Use Disorder – MDCalc

43. Questions?

44. Thank You