FW: Suboxone Update - Ordering Naloxone, standing order available in Colorado

Hi All!

Update on Naloxone (Narcan) prescriptions since we just worked through this in clinic today, pharmacists please feel free to chime in with other advice-

We had some difficulty ordering this in Epic  –  we found individual orders for “Ezvio” or Naltrexone auto-injector or nasal spray but not a kit.   If anyone has figured out the best way to order, please let us know.

However – speaking with the pharmacist there is a standing order for any patient or family member available in Colorado – it can be for either the nasal spray (vastly preferred by patients and families) or the autoinjector or an IM injection.  If a patient requests Narcan the pharmacist will talk to the patient and see which type they prefer and which is covered by their insurance.  The prescription is sent out under Dr. Wolk in Denver (CMO of Colorado Department of Health)

Here is the link with the protocol if you have questions-

https://www.colorado.gov/pacific/sites/default/files/PW_Naloxone-standing-orders-template_Pharmacy.pdf

Beth G

From: Insel, Kimberly J
Sent: Wednesday, September 05, 2018 2:49 PM
To: Brown, Cory J <CoryBrown@Centura.Org>; Dill, Jessica C <JessicaDill@Centura.Org>; Edwards, Gray K <grayedwards@Centura.Org>; Gayer, Corinn L <corinngayer@Centura.Org>; Mahony, Gwyn E <gwynmahony@Centura.Org>; Mathias, Tanner D <tannermathias@Centura.Org>; McClenahan, Kaitlin E <kaitlinmcclenahan@Centura.Org>; Neisler, Justin B <JustinNeisler@Centura.Org>; Pearson, Lindsey J <LindseyPearson@Centura.Org>; Saad, Amira O <amirasaad@Centura.Org>; Stowers, Lucas K <lucasstowers@Centura.Org>; Wendt, Rebecca A <rebeccawendt@Centura.Org>; Aquila, Emily C <EmilyAquila2@Centura.Org>; Baker, Stephanie <StephanieBaker2@Centura.Org>; Cammarano, Julian A <JulianCammarano@Centura.Org>; Del Moral, Spencer R <SpencerDelMoral@Centura.Org>; Galbraith, Bryce K <BryceGalbraith@Centura.Org>; Heng, Peter <PeterHeng@Centura.Org>; Holland, Hailey B <HaileyHolland@Centura.Org>; Maurer, David E <DavidMaurer@Centura.Org>; Pigott, Christine <ChristinePigott@Centura.Org>; Sterry, Brandon <BrandonSterry@Centura.Org>; Vollmer, Jeremy C <JeremyVollmer2@Centura.Org>; Zerba, Emily S <EmilyZerba@Centura.Org>; Baxter, Kelly <KellyBaxter@Centura.Org>; Blumberg, Drew T <DrewBlumberg@Centura.Org>; Bowie, James W <JamesBowie@Centura.Org>; Bross, Theodore L <TheodoreBross@Centura.Org>; Buehrer, Beth <BethBuehrer@Centura.Org>; Hart, Taylor V <TaylorHart@Centura.Org>; Sherman, Kelsey J <KelseySherman@Centura.Org>; Sofia Davies <SofiaDavies@Centura.Org>; Troutman, Jesse E <jessetroutman@Centura.Org>; Weniger, Kate C <KateWeniger@Centura.Org>; Beukema, Kylie <KylieBeukema2@Centura.Org>; Karozos, Stephanie <StephanieKarozos@Centura.Org>; Knaus, Chad J <ChadKnaus@Centura.Org>; Mathern, Seth A <sethmathern@centura.org>; Mettler, Lisa <LisaMettler@Centura.Org>; Rudolph, Michael R <MichaelRudolph@Centura.Org>; Diaz, Sara <SaraDiaz@Centura.Org>; Flint, Ryan <RyanFlint@Centura.Org>; Groff, Elizabeth <ElizabethGroff@Centura.Org>; Harrington, Trevor E <TrevorHarrington@Centura.Org>; Insel, Kimberly J <KimberlyInsel@Centura.Org>; Liegl, Sarah <SarahLiegl@Centura.Org>; Ludemann, Matthew MD <MatthewLudemann@Centura.Org>; McGee, Colleen M. <ColleenMcGee@Centura.Org>; Ochs, Genevieve <GenevieveOchs@Centura.Org>; Price, Bethany R <BethanyPrice@Centura.Org>; Strickland, Laura E. <LauraStrickland@Centura.Org>; Tamura, Krystal <KrystalTamura@Centura.Org>; Veres, Sharry <SharryVeres@Centura.Org>; Walter, Kimberly <KimberlyWalter@Centura.Org>; Zarza, Christina <ChristinaZarza@Centura.Org>
Subject: Suboxone Update

Dear faculty, staff, partners,

As a team we have chosen to introduce Medication Assisted Treatment into our clinics. This decision was made in response to the increased number of deaths we have seen in our patients suffering from opiate use disorder in Colorado.  We feel it is essential for us to provide patients with an opportunity to survive living with this disorder.  As a result, we will be offering Medication Assisted treatment in the form of suboxone inductions, group visits for patients on a stable dose of suboxone, Behavioral health support for patients suffering from opiate use disorder, and help with transitions to higher level care at Behavioral Health Group or Community Reach (when needed). 

Our first induction will be scheduled on September 10^th. We are hoping to schedule one induction (start of suboxone treatment) every Monday afternoon over the next few weeks.  Any patient interested in induction must have a visit for a Opiate Use Disorder Assessment Intake with either me (Kim Insel), Sharry Veres or Erica Feinman prior to being scheduled for induction.  

Summary of Who, What, Where, When:

Who:

Physicians, PAs, and NPs:

In order to be successful with this project we will need  the help of everyone in our clinics. Specifically, we would like as many of our providers as possible (NPs, Pas, and Physicians) to receive their DEA X waiver for suboxone.  With this comes a training that will help our providers in understanding the approach to addiction treatment from a harm reduction perspective.  Additionally, we will need any provider with a patient interested in MAT treatment with suboxone to contact Erica Feinman and Valerie Candia.  Erica and Val will put your patients on our registry and get them connected into our MAT treatment intake.  Patients are great candidates for MAT treatment if they would like to stop using heroin or illicit pain medications and if they are not on or willing to taper off any benzos or alcohol.

Step 1:  If you have a patient with Opiate Use Disorder (See definition below), first order Narcan to their pharmacy

Step 2: Next, ask if they are interested in medication assistant treatment

2a: If yes, contact Val and Erica (Val Candia and Erica Feinman) to get them scheduled for an intake appointment.

If yes, please order LFTs, HIV, HepC ab, Hep B Surface ag, and pregnancy test. Please do Urine dip with POC Drug of abuse test

2b: If no, please STILL contact Val and Erica to have them placed on registry under “not yet interested in treatment”

3: If after a patient completes their intake Erica recommends them for treatment, the PCP will be asked to order their induction dose (16mg) to the pharmacy at 144^th. If the PCP does not have an x number, the patient will need to be assigned a secondary prescribing PCP with a X number.

We will need additional providers to staff this clinic starting at the end of October. If you are interested please contact me, Val, Erica, Destanie, or Sharry.

Val and Erica: Will be maintaining the registry of patients on suboxone or in need of MAT on our share drive. Please contact them with any questions

Behavioral Health: Included in MAT is a longitudinal behavioral health curriculum on addiction management.  All patient in MAT will need to have monthly support from BH either in the form of group visits or behavioral counseling.  Complex patient who suffer from co-morbidities such as major depressive disorder, schizophrenia, bipolar disorder, will need additional support from a psychiatrist and may be better served by Community Reach for their MAT needs.

Health coaches/MSW Interns: Will assist patients in navigating cost questions around suboxone cost and cost of appointments in our clinic to engage in MAT.

What: Medication Assisted Treatment with Suboxone is a chronic disease management strategy for patients with opiate use disorder. Ideal candidates are interested in no longer using heroin or illicit drugs, are not on benzos and do not use alcohol, and are willing to come to our clinic weekly for at least a month then monthly indefinitely.  MAT has been shown to be more effective regarding survival than asking patients to stop using heroin without MAT support.

Where and When: We will begin Inductions and Suboxone group visits at 144^th.  September 10^th at 1 PM we will schedule our first induction with our first patient.  Group visits for patients with >4 weeks of stable suboxone dose and approval from PCP will be enrolled in monthly group visits (where they will receive prescriptions) every third Wednesday from 3-4:30 at our 144^th clinic. We hope to expand access to 84^th in 2019.

Please filter all questions regarding process or any suggestions to Erica Feinman, Kim Insel, or Sharry Veres. Any referrals should be routed to Erica and Val.

I believe what we are doing is incredibly important and will help save the lives of many of our patients. Thank you for being a part of this process.

Best,

Kim Insel, MD MPH

DSM-5 DIAGNOSTIC CRITERIA

The DSM-5 indicates that essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to the use of the substance. To assist with organization, Criterion A criteria can be considered to fit within overall groupings of impaired control (criteria 1-4), social impairment (criteria 5-7), risky use (criteria 8-9), and pharmacological criteria (criteria 10-11). Of note, the word “addiction” has been omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation. The more neutral term substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive drug taking.

Opiate Use Disorder: The criteria describe a problematic pattern of opioid use leading to clinically significant impairment or distress. There are a total of 11 symptoms. At least two symptoms of the following must be present within a 12 month period to meet OUD criteria.

(1) taking opioids in larger amounts or over a longer period of time than intended;

(2) having a persistent desire or unsuccessful attempts to reduce or control opioid use;

(3) spending excess time obtaining, using or recovering from opioids;

(4) craving for opioids;

(5) continuing opioid use causing inability to fulfill work, home, or school responsibilities;

(6) continuing opioid use despite having persistent social or interpersonal problems;

(7) lack of involvement in social, occupational or recreational activities;

(8) using opioids in physically hazardous situations;

(9) continuing opioid use in spite of awareness of persistent physical or psychological problems;

(10) tolerance, including need for increased amounts of opioids or diminished effect

(11) characteristic withdrawal pattern without use of opiate

Specify current severity

Mild: 2-3 symptoms

Moderate: 4-5 symptoms

Severe: 6 or more symptoms

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