Welcome to the Provider Clinical Support System, Waiver Training. This is now Module 8. My name is Dr. Stephen Wyatt, I'm an Addiction Psychiatrist and the Medical Director for Addiction Medicine for the Atrium Health System in Charlotte, North Carolina, and I welcome you. So the objectives of this module are to look at and address follow-up visits, how do you talk to patients, and work with patients over time that are taking medication to treat their problems. What are the key elements to documentation and record keeping? Then strategies to help people stay in recovery. First of all, I want to say, to encourage patients to recognize the treatment does work, that people can get in successful recovery. It's just so important for us to give patients some hope, and that hope is well-documented as you've seen in the other modules, that there's very good evidence that these medications can help reduce their cravings significantly and help them be stronger in their recovery, but it does take work, and there's an adage in the recovery community, "It works if you work," and that is, not only take the medication but do some of the things that we encourage, to help move them along in terms of the healthiness of their recovery. On top of that then is, how are we using language around talking with these patients? Not only our words, but our body language. That is making eye contact, really engaging with patients, and recognizing. Particularly early on as you're building a relationship with them, that there's been some very difficult things that they've experienced in their lives. There's significant overlap of sexual abuse, particularly with women in this population and thoughts of hurting themselves, things that they've been involved in that they are very potentially ashamed of. It's important that you don't be judgmental, that you begin to recognize, as I hope you are now able to as you understand these patients more clearly, and what is the long-term development of this problem that you have greater empathy in talking with them. To be able to use motivational interviewing as you approach the patient to help them get better engaged is important, and it's something that you can use just in your general talking to patients. How do you pick up on their change talk in a way that you can engage them more effectively in moving forward? You want to emphasize that the most consistent predictors of a successful outcome is retention in treatment, staying in treatment, and then active involvement in their treatment, which can include community support for recovery. What are they doing? How are they engaging in a larger population or healthier population? Some in recovery and some that are just involved in doing healthy activity is going to improve their recovery. If the patient does drop out, make efforts to contact the patient with compassion and understanding that this is a chronic illness, and encourage patients to re-engage in treatments. So particularly, patients can relapse for a day or two and feel pretty disheartened that this is going to work, sometimes family finds out right away, they become disgruntled with them. For us to then engage and say, "Come on back in. What did you learn from that relapse?" Try to help them more quickly, get back into a recovery program. It certainly can happen whether out for weeks, months, maybe years before they come back in, but tend to talk to them about what happened? What could you learn from that relapse and how might we prevent it in the future? So again, addiction is one of the most stigmatized conditions. Really, there's prejudice in the healthcare community and the population at large against people that have these illnesses. As you've heard, it could be often associated with genetic predisposition, adverse turn of events. These are things that the children have no control over; how drugs and alcohol are used in their home. So to not think of it as just weak will, there are so many precursors that go into the development of the problem. Then when the problem develops, then it is a profoundly ingrained or there are profound changes that take place neurobiologically that keep a person locked into this problem. So individuals with substance use disorders are viewed more negatively than people with physical or other psychiatric disabilities. So stigmatizing language like a substance abuser rather than a person with a substance use disorder can adversely affect the quality of care and subsequent treatment outcomes because they feel comfortable coming in to see you because you treat them like a real person. So there's a broad consensus for adoption of clinical non-stigmatizing person-first language for substance use problems in these professional organizations. I really encourage you to learn about this and consider more thoroughly. So language of recovery, you want to be respectful as you would with anyone, non-judgmental, be honest with them at the same time, make instructions clear and understandable, and continue to be supportive. How could you be more helpful to them? Listening to them, making patient-centered care in a way that what is their goal? How do you tie into their goal of good therapeutic plan? I think to again, consider the language that you're using, staying away from addict or clean, clean and sober. Clean and dirty urines are often just pejorative in some ways. Certainly, terrible things like junky and pejorative terms to these individuals. I say this not only how you would talk with them, but how you talk to your staff, how you talk within your office about people with substance use problems, can begin to change the language and thus the behaviors and reduce this stigmatization in the office in general. So follow-up visits, then they can be and they eventually get to be very straightforward. They are typically 15 to 20 minutes. You frequently will see them in a more frequent pace or in the beginning of treatment. You can control that pretty closely by how much medication you give them at any one time, so they will come back for medication. So if you have concerns about them, you write a shorter script and they come back more frequently. You want to open up discussions, at least opening it with an open-ended questions so it's not a yes or no answer. But in general, describe to me how things have been going for you, as opposed to are you doing okay. So you're not leading them into specific answers. You want to understand what are their symptoms in terms of are they stable, are they stabilizing? Are they craving still, what are the triggers been? How are they feeling? Self-reported use of illicit or non prescribed substances. As this happens and as you create more of a relationship, you will find that they are open about telling you, [inaudible] "I smoke some marijuana last Friday night. I was with these friends, and it just seems so hard to say I didn't want to partake. It was hard for me." Those can be things that then with a counselor or with you, you can do some role-playing. How do you say no when this is a person that has been saying yes for many years. So monitor adherence and the response to treatment, and whatever adverse effects that they might be having to medications that you're prescribing. Challenges and changes in their psychosocial situation, financial, living situations. There's an acronym for SOBER, that is S-O-B-E-R and it's "son of a bitch, everything's real." That is people get into recovery and there can be a bit of a pink cloud around it that people are happy with me and I'm happy with myself. I'm sleeping better, eating better, all these things. But three, four months down the line, there's problems with the child or problems with their work or house payments, car payments. I mean, there is real life and it's not like all their struggles are going to go away because they got this problem under control. So it's important to just bring them back to where was it, and being able to play it forward if you were to relapse because of these struggles, where would you be. Review the lab results with them. Review the treatment plan over and over again. That is your expectations, their expectations, how are we moving. It may change sometimes as time goes on in terms of what are their goals. Then lastly, what's the safety profile. Are they experiencing suicidality particularly if they voice problems with or if they had problems with depression? What have you told them in the past about overdose prevention? Do they have access to naloxone in the home? You want to encourage that there's some lifestyle changes and are they attending SOBER support groups or building others SOBER relationships. Are they abstaining from non prescribed opioids or other addictive substances clearly, and how did they utilize community sports most effectively in moving forward in their own recovery? Then leaving a moment that allow them to ask questions or voice their concerns. In terms of documentation, again, you're going to write down a little bit of their subjective response in terms of how they're doing, what they're experiencing, and then what symptoms they may be experiencing. You want to be clear that you've documented the diagnosis and potentially other diagnoses that could be having an effect on their drug use. Those in general that you're monitoring, their depression. Your monitoring their treatment of PEPSE or whatever it might be. Medications that are being used. Substances that might have been self-reported or what you might then find on lab results. If there have been other concerns to document that you went through a safety risk plan in terms of this day. Truly started thinking more seriously, or had a plan for self-harm, that they would go to an emergency room, or at least be in touch with your office. So again, these are all things that you would typically have. I mean, my notes are essentially a soap format, and it's fitting in or considering these other details within a subjective, objective plan, and then being able to go forward. In terms of screening, you have documented. Again, if there's thoughts of self-harm and what are you potentially doing about it. If it's very clear, then you would want to make a referral to the emergency department, and they may end up getting hospitalized. Is there a risk of harm to others, and this would be the duty to want. If you hear very clear threat to someone else, then it may be something that you would want to report. Is there an overdose risk? For the most part, all these patients should have naloxone available to them. So either give them a prescription, tell them other resources in the community where they can get naloxone. Many states now there's access to naloxone behind the counter. It's not out on the floor but it's behind the counter and available without a prescription. But at the same time, there's also many programs around the country where naloxone is being made available for free, and to look into where that might be in your community if a person doesn't have insurance and make patients aware of that. Document clinical decision-making around these risk assessment and safety plan. So these folks do have a federal regulation around their records and this is referred to as 42 CFR Part 2, and it essentially tightens it up even closer because in many ways of this stigmatization that I've described. So it is important that you obtain assigned patient consent in disclosing individually identified addiction treatment information to a third party. Now, if you're in a primary care clinic and you're treating a patient for a variety of things along with a substance use disorder with medication-assisted treatment, this does not apply. If you're not treating them in a substance abuse treatment center of some kind, then you can share their data. So you don't have to worry about that necessarily by this law. At the same time, it's important to be aware of the stigmatization that if you are going to be sending records, you could recluse it. I hate to say that because I really wanted to be a part of general medical care that we should know that person is getting treated for an opiate use disorder always or other drug use disorders. If it didn't have the stigmatization, it would be more readily available, that all treaters would be aware of that and be able to encourage them or reward them when they're working on their recovery. But we're going to be treating something that could put you at risk. So these are the things that we will do. Not saying I can't treat you or I'm not going to treat your pain or that thing, but I just encourage you to recognize that there is not a law against how you share this information if you're sharing it from someplace other than a mental health or a substance abuse treatment setting. But I also want to include that, to give the person that you're sharing the information with the telephone call or have collaborative care is just so important. There's a lot more information about this on both PCSS modules, but also at the samhsa.gov site that is available to you here. So you can learn more about confidentiality laws, particularly if you're in a substance abuse treatment setting. It is federally regulated and it's important for us to understand how we would use this, what we would do. If you have a primary care office and you have separate stationary that says Addiction Treatment Center of some kind, you would fall under this law. But if you're primary care, you're treating them for general medical problems and they happen to also be on buprenorphine, naltrexone, whatever, they carry a diagnosis of substance abuse problem, that does not fall under this law. So you want to also keep the records safe and they're typically behind two lock doors. So it can be a black cabinet, most places now it's electronic health record with a password to get into the record. So there's a lot of confidentiality built into those systems, but they should be kept safe. They need to be kept available to both state and federal purview potentially if need be, and they must be again in a double-lock situation, electronic health records, to meet its regulation. The Drug Enforcement Agency under this law does have the potential for coming into a site where patients are getting opiate use treatment and potentially doing a review. That is, that you're compliant with record keeping and following the law. Now, typically, in the past and this is happening far less frequently than it had been, but in the past, we were being asked how many patients are you treating. They want to know that you're not treating greater than your allowable number of patients and how are you're storing the records. That was about it. They then might get in a conversation around what's your average dose. These were things that they were very interested in a number of years ago just to get a sense of how it's being prescribed, how you are prescribing maybe compared to others. They're doing far less of these interviews now. The one way in which they do use it more frequently is when you are distributing buprenorphine from your office. So when you're distributing a controlled substance from your office, these then become audits, not just an interview. But again, we're seeing these much less frequently and that's in part because they have the prescription monitoring program with this information already. So it's those that are really outside the norm. It's not saying that they're breaking the law. But if you're outside the norm, there can be problems. If they're seeing a lot of diversion of medication under your name, which often means you're outside the norm in terms of how much you're prescribing at a time or what interaction you're having with patients, that might also be an indication of why they may come by for an interview. So they want to know that there's full identifying information of the patient including name and address, the medication name, strength, and dosage form, quantity, and direction of use. This is on the prescription for buprenorphine, naloxone must be dated and signed on the day that it's issued, and the provider must have their X number on the prescription. Typically, it would be your DA number and an X number. So a lot of I prescribe electronically or the prescription is written electronically as my DA number, but my X number I'll just write that on it. Office-based buprenorphine treatment storage and dispensation. If you're actually dispensing it from your office, then you certainly need to keep the medications secure. You need to be keeping a very close record of how you are dispensing the medicine. So every dose should be documented. Either you still have it or it's been dispensed to a specific person, the number and who you'd spend it to. So it does increase the scrutiny and the importance of how your office is setup. Now this is not done very often, but if you do, you should review the law yourself again and make sure that you're compliant. So supporting recovery. You want to use good prescribing and monitoring techniques to reduce the possibility of diversion. This has been gone over on a number of the modules. Use the dose that people need to reduce their cravings. If they're working at the recovery at all, typically if they did get up to a higher dose, they're able to come down on the dose some over time. When they stop it, it's up to them in many ways. But reducing the dose can give you a stronger indication that they're not selling some of their medication. So you want to just do some good prescribing, have good prescribing habits, and constant monitoring. Use patient-centered care, patient-directed care and consideration for the patient's autonomy. Focus on their strengths rather than reducing their deficits. What are you working towards? What things did you use to enjoy? Do you consider getting back into some of those things? [inaudible] to participate in community resources that might be available to them. Inclusion of data gathering in terms of how am I doing and how does this compare to some of the evidence-based that I've seen and how might I adjust my office. Could it be office personnel that are still in conflict with this? What are the tools, and there are tools with the PCSS. So how your office personnel can be interacting or more comfortable with a population? Again, you may find out as we have many times that someone in your office actually had someone in their family that either had a severe problem and it caused all kinds of chaos or had someone in their family that had a problem, got into recovery, and is now doing very well on medication. So they're very receptive too. This medication worked really well for my uncle Joe. So these sorts of things will come out potentially over time and people start to get more and more comfortable. Again, I will also say that as people get into recovery, they often are great patients to take care of and many times office personnel begin to recognize that that it's not the stigmatized patient that I thought it would be. Instead, it's an individual and it's an individual with their own story, and as they've gotten into recovery, become very compliant and enjoyable patient to have come to the office. So limits and contingencies, accountability about clearly defining examples and consequences. What will happen if this happens? Be very clear and follow up appropriately. Now again, everyone is an individual. So you may have a little bit more of interest hanging with this person because you've seen elements of them moving forward and they have family strengths, whereas someone else you see something similar objectively, but you feel very uncomfortable about them being able to do well in your level of care. So then you might make some changes. I use and I brought this up in other ways and in these modules that I've taught, I'll use the length of the script as a contingency. If they're doing really well, we start extending that. If they start having problems, we shorten it and they get in to see us more frequently so that we're able to follow them. So it's the frequency of visits, maybe changing the dose in some way, and then if there's continued problems, we bring them to a higher level of care. No one is kicked out of treatment. We wouldn't do that with any other disease. We want to give them an alternative in terms of how they could potentially move forward. So addiction is a chronic disease. This is a cartoon put together by Tom MacLellan, and I think it's just so appropriate. In this first graph, this is hypertension, diabetes, asthma. They've got a problem, we give them a specific medication. They do really well. We take that medication away. They have an exacerbation of their problem, we say, "Boy, this treatment works pretty well. This is worth checking out." Whereas in substance use problems, we often will have someone with a severe problem, we put them into treatment, send him to a 28-day program. They're there. They've cleared their heads, family comes, they say all the right things, things are good, and they're again in controlled setting, there's not environmental triggers, they're not using, but then they go home and they relapse and we say treatment doesn't work. We can say the same thing about medication. We have them on medication for awhile. Well, how long do they need this? Well, they need it as long as they need it. So there's going to be some people we can taper off and they do very well, and they really feel like we've built supports around them that they are ready to come off medication and leave the door open if there's problems. There are other people that don't have those supports, that have done poorly for a long period of time, or they have other mental health problems. There can be a whole variety of things that result in them staying on the medication, feeling comfortable moving forward in their life and they have problems. Is it worsening in some ways? Is it a brain change that results in some people feeling comfortable coming off the medication and others not? Is it the degree of the problem? We would look at that at any other chronic illness. They're asthmatic or diabetic that's on an insulin and an oral hypoglycemic, and then they lose a lot of weight and they come down on their insulin needs, and they get down to a very reasonable weight, and they're exercising regularly, and we try to take them off medication and they're unsuccessful, and they need to stay on oral hypoglycemic. It's how much damage to the pancreas was there with profound obesity. So think about this in a similar way in terms of brain disease. It's not dissimilar in terms of being a chronic illness. So as long as the patient participates in the intervention is how long you want to keep it going. So treatment adherence comparisons. Many other chronic illnesses have similar percentages, if not worse. Diabetes, the percentage needing additional treatment in a year is not as good as substance use problems, hypertension, it's all very similar. So to think of substance use problems as being the relapsing illness is just not true. There's poor compliance with all chronic illness, and there's certainly relapses of the illness with various environmental changes. So in summary, it's important to have a clear clinical policies to address areas, situations relevant to office-based opioid treatment. Clear guidelines are key to ensuring that the patient is receiving treatment at the appropriate level of care. You set that up, they know what the expectations are, you know what the expectations are. There's variability in these specifics, and good documentation and record keeping are key to the delivery of subsequent treatment. These again can vary as per the individual or the office that you're working in, but it's key that this takes place. A record of clinical decision-making regarding choice of medication, dosing, rationale for drug screening and level of care is recommended. So here are the references that are available to you. Here is more about 42 CFR and just privacy protections. Again, looking beyond the law to really recognize that these patients are at risk of being stigmatized. So whether there's a law or not, to be in control of the record and being clear that it's not being picked up by people in your office and used inappropriately, or it's being sent in an uncontrolled fashion to someone that could potentially use it inappropriately is extremely important. As it is really with all medical records, but certainly this population most important. If you are at a treatment center, there are very clear laws around sharing this information. We do have a mentoring program and I encourage you to look at this. This is through the PCSS, and I would state that the mentoring program is really designed to offer mentoring assistance to those in need of more one-on-one interaction with one of our colleagues at the PCSS, one of the clinical experts, to address these clinical questions. You have the option of requesting a mentor from the mentor directory, or we'd be happy to pair you with one. To find out more about this, please visit the website and use the web link noted on this slide. So this would really help you if you have specific questions. We really want to see people be comfortable in using the medication and encourage you to ask questions, get a hold of us if you need anything. We also have a PCSS discussion forum. Ask a colleague and this offers a discussion forum, which is comprised of PCSS mentors with other experts in the field, who can help provide prompt responses to clinical cases or questions. We also have a mentor on-call each month that's available to address any submitted questions through the discussion forum. You can create up a new login account by clicking on the image on this slide and access the registration page. So these are really nice forums with a few different people are on it one time and questions get asked, and this group of experts can discuss the variabilities of whatever the question is and how it might be most effectively dealt with. These are all the different organizations that are involved in the PCSS. So this is a really nice consortium of groups that we get input from all these groups and consequently, they all know about it, there's been a significant increase and interest in this area. If you are part of one of these medical societies, I encourage you to look on their websites for other information because many of them are involved in this work. So with that, I appreciate that you've completed the training. Most importantly, I hope that if you're uncomfortable with starting to prescribe that you get in touch with us, but please go ahead and treat two or three patients. That low hanging fruit, that person that you feel most comfortable treating, get a feel for the medicine and I think that you'll see some very positive results and enjoy working with these folks. So thank you very much.