Project ADOPT
Project Advancing Drug and Opioid Prevention and Treatment (ADOPT) is a collaborative, multidisciplinary training initiative that includes physicians, nurse practitioners, and psychologists at 3 distinct universities and over 300 Northern California training clinics. ADOPT will be administered through the UCSF School of Medicine (SOM) with Co-I's at USF and SSU Schools of Nursing.
The purpose of this project is to improve opioid use disorder (OUD) outcomes in California by increasing the workforce of waivered, culturally competent medication-assisted treatment (MAT) providers and supporting the development of MAT-prepared clinics to remote and underserved regions. MAT competencies and systems improvement may substantially improve the medical care provided to clients with OUD. Developing greater awareness, knowledge, and skills may benefit both learners and clients and broader health care systems more generally.
This project is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA; Grant No: 1H79TI081654-01).
The Opioid Epidemic
The National Survey on Drug Use and Health data indicate that approximately 11.8 million people over the age of 12 misused opioids in 2016, constituting 4.4% of the American population.1 In California, an estimated 5.8 % of the population over 12 has misused opioids with higher rates among adolescents (7.3%) and among those living in rural communities.1,2 Opioid misuse contributes to a number of serious public health issues including addiction and dependence, unintentional overdose deaths, neonatal abstinence syndrome, HIV and hepatitis C.3,4 The economic cost of the opioid crisis is estimated at $504 billion or 2.8% of 2015 GDP.5 The cumulative economic cost to the United States since 2001 exceeds one trillion dollars.6
Although the overall trend in opioid misuse has decreased from a 2006 peak,7 the number of deaths from opioid overdose has continued to rise.3 It is estimated that 115 people die every day from an opioid overdose in America and in 2016 there were 1,919 opioid overdose deaths in California alone.2,3 The rural overdose rate has consistently surpassed the urban rate with the 26-34 age group at most risk.8 Non-metropolitan counties in Northern California have been identified as national hotspots for drug-related overdose mortality.9
Unmet Needs
- Screening, assessments, and referrals to treatment for opioid use disorders (OUD). Despite a growing awareness of the opioid epidemic and other substance use disorders (SUD), routine screening is infrequent or perceived as too cumbersome.10,11 Moreover, evidence-based guidelines for safe opioid prescribing have not been universally adopted or have met substantial obstacles from patients, providers, or health systems.12-15 Consequently, neither patients with early signs of misuse nor those with OUD are identified and supported appropriately. If clinics and providers are to address the opioid epidemic, “universal precautions” for opioids must be followed and patients with OUD must be either treated in house or referred to specialty care.16,17
- Patients have limited access to medication-assisted treatments (MAT). At present, less than half of private sector treatment programs offer MAT and, of those, fewer than 35% of clients receive MAT.18 In California, there are nearly 250,000 persons with an OUD without access to MAT2 especially in rural communities.19,20 Any efforts to improve access will have to include rural areas such as those in Northern and Central California. It is estimated that by adding a minimum of 3,525 active opioid agonist prescribers with a 30- patient panel limit, the treatment gap in California would be closed by almost one third (31.9%).2Unfortunately, access is limited by both individual and system level factors. Provider level barriers include beliefs about SUD treatment, a lack of training and/or confidence, MAT waiver requirements, stigma against patients with OUD, inadequate specialty referral support, and provider burnout.21-23 System level barriers include a fragmented health care system, opioid treatment facility licensure requirements, clinic workflows that do not facilitate universal substance use screening and indicated treatment, billing processes and organizational fiscal constraints, and longstanding attitudes and stigma around OUD and MAT.16,17,21
- Patients often do not sustain their engagement with MAT. Even if patients with OUD are successfully identified and offered MAT, treatment engagement may be difficult to sustain with dropout rates often exceeding 50%.24,25 Patients who discontinue MAT often rapidly return to opioid misuse and may then be at greater risk for overdose.21 Long-term use of opioid agonist therapy is often recommended but may be difficult to provide given case load limits and/or system regulations around dispensing methadone.21Treatment discontinuation is likely to be caused by a number of structural and interpersonal factors. Patients with OUD are more likely to be from vulnerable populations including youth, those living in poverty and homelessness, persons with a history of incarceration, and persons with major psychiatric and physical comorbidities.21 The structural barriers to treatment such as limited transportation, poverty, and violence can be difficult to address. Cultural factors such as language, literacy, and immigration status may cause patients to feel misunderstood or unable to trust providers. Training in structural and cultural competence (SCC) must go hand-in-hand with MAT competencies in order to sustain patient engagement in treatment.26,27
MAT for OUD – The Current State and Gaps in Knowledge
MAT (medication-assisted treatment) is an effective treatment among medically eligible and motivated patients and may include either antagonist (e.g. naltrexone) or agonist therapies.25,28,29 Although antagonist therapy can be effective, dropout rates approach 85% at 25 weeks.24,25 Agonist maintenance programs such as methadone and buprenorphine decrease mortality by up to 50%, decrease transmission of disease (e.g. HIV and hepatitis), decrease crime, and improve social functioning.29-32 There are insufficient outcome data to support the choice of one opioid agonist over another, however, the availability of buprenorphine through office based settings has increased the reach of MAT, particularly for rural communitites.33 Buprenorphine MAT requires the management of acute withdrawal, medication induction (in many cases), stabilization, maintenance and eventual drug tapering. Behavioral therapies are recommended for concurrent use with MAT34 although data demonstrating additional benefit are limited.25,29 Multidisciplinary, team-based care models have demonstrated increased effectiveness in the delivery and sustainability of MAT services.35
The Drug Addiction Treatment Act expanded the capacity of physicians to provide buprenorphine from office-based settings after the completion of 8 hours of training to obtain a DEA waiver to prescribe. The Comprehensive Addiction and Recovery Act in 2016 (CARA) allowed nurse practitioners and physician assistants to prescribe buprenorphine after 24 hours of additional training.21 Although this legislation has successfully increased the number of MAT providers, access still lags behind demand.2 Only 5% of physicians have obtained the waiver and, of that group, 72% have fewer than 30 patients.36 Innovative training programs such as Providers' Clinical Support System-Opioid Therapies (PCSS-O) and PCSS-MAT have trained over 6,000 providers through webinars, seminars, and coaching. However, these programs note that more attention needs to be given to screening, systems improvements, and addressing stigma.37 Improved access to and implementation of training is needed along with systems support for already trained, waivered providers.
Project ADOPT will improve OUD outcomes in California by increasing the workforce of waivered, culturally competent MAT providers and supporting the development of MAT-prepared clinics in remote and underserved regions. MD and NP learners will complete the PCSS waiver training (or equivalent) as an integrated component of their required curriculum in conjunction with practical field experiences. Training will include safe opioid prescribing, screening and assessment for OUD, and strategies to promote and sustain patient engagement in vulnerable populations. MAT training for clinical preceptors will be promoted through the use of internal champions and existing training and coaching resources through PCSS (Providers' Clinical Support System). Tailored, stepped technical assistance will be provided to clinical systems and administrators including strategically disseminated “implementation kits,” near peer support, telephone coaching, and regional workshops. Project staff will collaborate with the California Opioid Safety Coalition Networks in Northern California to identify additional MAT training opportunities and further collaborations to improve MAT service delivery.
References
1. United States Department of Health and Human Services [USDHHS] (2017). Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm
2. Lisa Clemans-Cope, Marni Epstein, and DougWissoker. County-Level Estimates of Opioid Use Disorder and Treatment Needs in California. The Urban Institute. May 9, 2018.
3. Center for Disease Control and Prevention [CDC] (2017a). Understanding the epidemic.
Retrieved 7/18/18 from https://www.cdc.gov/drugoverdose/epidemic/index.html
4. National Institute of Drug Abuse [NIDA] (2018a). Opioid overdose crisis. Retrieved 7/16/18 from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
5. Council of Economic Advisors (2017). The underestimated cost of the opioid crisis. Retrieved from https://www.whitehouse.gov.
6. Altarum (2018). Economic toll of opioid crisis in U.S. exceeded $1 trillion since 2001.
Retrieved 7/20/18 from https://altarum.org/about/news-and-events/economic-toll-of-opioid-crisis-in-u-s-exceeded-1-trillion-since-2001
7. Substance Abuse and Mental Health Services Administration [SAMHSA] (2017). The CBHSQ reports. Retrieved from https://www.samhsa.gov/data/sites/default/files/report_3186/Spotlight-3186.html (9)
8. Mack KA, Jones CM, Ballesteros, MF. 2017. Illicit Drug Use and Drug Overdose in Metropolitan and Non-metropolitan areas — United States. MMWR. Morbidity and Mortality Weekly Report. 66:1-12. https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm
9. Monnat, S. M. (2018). Factors Associated With County-Level Differences in U.S. Drug-Related Mortality Rates. American Journal Of Preventive Medicine, 54(5), 611-619. doi:10.1016/j.amepre.2018.01.040
10. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A Single-Question Screening Test for Drug Use in Primary Care. Arch Intern Med. 2010;170(13):1155-1160.
11. Wickersham JA, Azar MM, Cannon CM, Altice FL, and Springer SA. Validation of a Brief Measure of Opioid Dependence: The Rapid Opioid Dependence Screen (RODS). Jrnl Correct Healthcare 2015;21:12-26.
12. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep 2016; 65(No. RR-1):1-49.
13. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing
rates by specialty, U.S., 2007-2012. Am J Prev Med 2015; 49: 409-13.
14. Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P, and Chou R. Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain. Ann Intern Med. 2014;160:38-47.
15. Volkow ND, and McLellan AT. Opioid Abuse in Chronic Pain —Misconceptions and Mitigation Strategies. N Engl J Med 2016;374:1253-63.
16. Saloner B; Stoller KB; Alexander GC (2018). Moving addiction care to the mainstream – Improving the quality of buprenorphine treatment. The New England Journal of Medicine, 379 (1), pp. 4-6
17. Volkow ND, Frieden TR, Hyde PS, Cha SS (2014). Medication-assisted therapies: Tackling the opioid overdose epidemic. NEJM 370:2063-66.
18. Knudsen HK, Abraham AJ, Roman PM. Adoption and implementation of medications in addiction treatment programs. J Addict Med 2011;5:21-7.
19. Andrilla CHA, Coulthard C, Larson EH. Changes in the Supply of Physicians with a DEA DATA Waiver to Prescribe Buprenorphine for Opioid Use Disorder. Data Brief #162. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, May 2017
20. Jones, E. B. (2018). Medication-Assisted Opioid Treatment Prescribers in Federally Qualified Health Centers: Capacity Lags in Rural Areas. Journal Of Rural Health, (1), 14. doi:10.1111/jrh.1226
21. Mccarty, D., Priest, K. C., & Korthuis, P. T. (2018). Treatment and Prevention of Opioid Use Disorder: Challenges and Opportunities. Annual Review Of Public Health, 39525-541. doi:10.1146/annurev-publhealth-040617-013526 (12)
22. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. (2015). United States, North America: Lippincott Williams & Wilkins.
23. Huhn AS, Dunn KE. (2017). Why aren’t physicians prescribing more buprenorphine? JSAT 78:1-7.
24. Johansson BA, Berglund M, Lindgren A. Efficacy of maintenance treatment with naltrexone for opioid dependence: a meta-analytical review. Addiction 2006;101: 491-503.
25. Schuckit MA. (2016). Treatment of Opioid-Use Disorders. NEJM 375(4):357-68.
26. Hansen H, Metzl J, (Eds.). Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice [Special Issue]. Journal of Bioethical Inquiry. 2016;13(2):179-183.
27. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science & Medicine. 2014;103:126-133.
28. NIDA. Medications to treat opioid use disorder. Bethesda, MD: National Institute on Drug
Abuse (NIDA), 2018.
29. Weiss RD, Rao V. (2017). The prescription opioid addiction treatment study: What have we learned. Drug and Alcohol Dependence 173:S48-54.
30. D’Aunno T, Pollack HA, Frimpong JA, Wuchiett D. Evidence-based treatment for opioid disorders: a 23-year national study of methadone dose levels. J Subst Abuse Treat 2014; 47: 245-50.
31. Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev 2011; 8: CD004145.
32. Pierce M, Bird SM, Hickman M, et al. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction 2016; 111: 298-308.
33. Stein, B. D., Gordon, A. J., Sorbero, M., Dick, A. W., Schuster, J., & Farmer, C. (2012). The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: Recent service utilization trends in the use of buprenorphine and methadone. Drug And Alcohol Dependence, (1-3), 72.
34. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. (2015). United States, North America: Lippincott Williams & Wilkins.
35. Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A. Primary care models for treating opioid use disorders: What actually works? A systematic review. Plos ONE [serial online]. October 17, 2017;12(10):1-40. Available from: Academic Search Complete, Ipswich, MA. Accessed July 15, 2018.
36. SAMHSA, Physician and Program Data – accessed 07/17/2018
37. Levin FR, Bisaga A, Sullivan MA, Williams AR, and Cates-Wessel K. A Review of a National Training Initiative to Increase Provider Use of MAT to Address the Opioid Epidemic. Am J Addict. 2016; 25:603-609.