"Suboxone Saved My Life" - Opioid Use Disorder (Part II) Artwork

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Primary Care Pearls

"Suboxone Saved My Life" - Opioid Use Disorder (Part II)

July 25, 2022 • Primary Care Pearls (PCP) Podcast • Season 1 • Episode 2

In the second episode of our opioid use disorder series, we’ll explore medications and treatment options for the disease. Our patient TJ joins and continues to offer her perspective. Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===

Introduction (0:00)
Chapter 5 - Risk Assessment and Harm Reduction (3:43)
Chapter 6 - Medication Assisted Treatment (11:31)
Chapter 7 - Counseling on Treatment Options (15:47)
Chapter 8 - How PCPs can start treating OUD (28:16)
Conclusion (33:04)

=== Learning Points ===

The RIP-TEAR mnemonic can assist in taking a good history of a patient with an opioid use disorder.
There are three FDA-approved medications for the treatment of opioid use disorder: methadone, buprenorphine (i.e. Suboxone), and naltrexone.
Physicians who would like to prescribe for up to 30 patients do not require additional training to receiving an X-waiver, thus removing one barrier to treating opioid use disorder within the primary care setting.

=== Our Expert(s) ===

Dr. Carolyn Chan is an academic hospitalist at Yale New-Haven Hospital with interests in medical humanities, quality improvement, and addiction medicine. You can reach her on twitter @CarolynAChan.

Dr. Lisa Sanders, MD, FACP, associate professor of medicine (general medicine) and author of the popular Diagnosis column for the New York Times Magazine offers her media expertise to the PCP team as a production consultant for the podcast.

=== References ===

[FDA] Information about Medication-Assisted Treatment (MAT): https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat
[SAMHSA] Become a Buprenorphine Waivered Practitioner: https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner

=== Recommended Reading ===

Buresh M, Stern R, Rastegar D. Treatment of opioid use disorder in primary care. BMJ. 2021 May 19;373:n784. doi: 10.1136/bmj.n784. PMID: 34011512.
Alexander GC, Stoller KB, Haffajee RL, Saloner B. An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19. Ann Intern Med. 2020 Jul 7;173(1):57-58. doi: 10.7326/M20-1141. Epub 2020 Apr 2. PMID: 32240283; PMCID: PMC7138407.
Hoffman KA, Ponce Terashima J, McCarty D. Opioid use disorder and treatment: challenges and opportunities. BMC Health Serv Res. 2019 Nov 25;19(1):884. doi: 10.1186/s12913-019-4751-4. PMID: 31767011; PMCID: PMC6876068.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts for furthering the medical education of residents and clinicians in early stages of their careers that include contributions from patients themselves, who have the autonomy to share their own experiences of how their primary care physician directly impacted the quality of their care.

Hosts: Nate Wood, Maisie Orsillo, Addy Feibel
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Producers: Helen Cai, Addy Feibel
Other background music: OfShane, Lesfm, ComaStudio, penguinmusic, Ammil, Lauren Duski, and Slynk

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Addy: Hi everyone. My name is Addy Feibel,

Nate: And my name’s Nate Wood,

Addy: …and welcome to primary care pearls, a podcast made by learners for learners. And most importantly led by our patients’ stories. Today,

[00:11:07] I remember taking my first dose of Suboxone. I, it it's fresh in my head. I never forgot, um, feeling, um, a sense of normalcy because I had, I hadn't felt that in a long time. I haven't felt like myself in a long time. So when I first took Suboxone, I never forget telling the doctor that I felt normal.

Addy: Today, we’ll be talking about medications for opioid use disorders, part 2 in our OUD series.

Audio track 3

Addy: For centuries, society has seen addiction as this moral failing. There’s a prevailing narrative that individuals who cannot stop using simply do not have the willpower or don’t want to. As a result, many of our patients with OUDs feel a great deal of shame and guilt about their opioid use. However, opioid use disorder is a chronic medical condition. And like diabetes and hypertension, there are several highly effective medications that increase patient survival. These medications, which are firstline for treating opioid use disorders, can also significantly improve the quality of life of our patients.

Addy: During our discussion, we will be joined by TJ, a patient living with opioid use disorder.

[00:00:28] Hi, I'm TJ. I am one of the patients that the clinic arc and, um, I've been part of arc for about five years.

Addy Through her experience, we’ll learn more about the effects of OUD medications and the importance of involving the patient in deciding which medication is right for them. We’re also joined today by addiction medicine expert and Yale School of Medicine primary care physician Dr. Caroline Chan.

[00:00:32] Hey everybody. My name is Caroline Chan. I am so happy to be here and talk about one of my favorite topics, the treatment and care for patients with opioid use disorder. I am an internal medicine physician and an addiction medicine physician. Nate: Besides my voice, you’ll also hear the voice of my friend and stellar resident physician Dr. Maisie Orsillo in our discussion with Dr. Chan.

Addy: With the conversation facilitated by resident interviewer, Dr. Mariah Everts

[00:00:00] So I'm Mariah Everts, I'm a third year resident this year and the primary care program at Yale. I've been particularly interested in addiction medicine as a resident. Um, and so I've spent a bunch of time in our addiction recovery. Which has been one of my favorite parts of residency

Addy: Our discussion today is all about the different types of medication to tread OUDs: how they work, how to decide which one to pick, and how to start prescribing them to our patients.

Addy: My name is Addy Feibel, and I’m a second-year medical school student at the Yale School of medicine.

Nate: And my name’s Nate Wood. I’m an internal medicine physician and medical education fellow at the Yale School of Medicine. Besides my voice, you’ll also hear the voice of my friend and stellar resident physician, Dr. Maisie Orsillo in our discussion with Dr. Chan.

Maisie: This is Maisie, a PGY-2 in the primary care program

Addy: And we’ll be your hosts for today’s episode.

Addy: Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you, or a loved one is suffering from anything covered in today's episode, be sure to discuss it with your medical provider. Now, on to the show!

Chapter 5: History post diagnosis and risk management.

Addy: In last week’s episode, we discussed how to screen for Opioid Use Disorder with the 3 C’s: loss of control, cravings, and consequences, and how to use that information to then make a diagnosis. Today we’re going to transition to talking about what comes next: treatment.

Nate: And for the treatment of opioid use disorder, medication is a key component. But in order to decide what medication is most appropriate for each of our patients, we first need to take a good history. Dr. Chan has an easy-to-remember mnemonic to help us with that.

Maisie: And just stepping back for the primary care physician I think this is such a ripe opportunity to engage with patients to get a comprehensive history

[00:20:02] Can I add onto that? How do you, how do you take a history? Right? Like what, what do you need to know? So after we make it a diagnosis, I like to use the RIP-TEAR mnemonic, which I learned here from, from Janette Tetrault, Dr. Tetrault. So what does rip tear stand for? So, number one, if you remember one thing, remember the R risks you want to know about what a patient's risks are, right?

[00:20:21] What is their risk of overdose? What's their risk of alcohol withdrawal. Right? I want to know, is there something life-threatening going on that I need to intervene on right now to help keep the patient safe? The, I stands for initiation. I do like to ask the age at which the patient patients started to use the substances because it just kind of helps frame what their treatment plan will be for me moving forward, the P stands for pattern.

[00:20:47] So that's when I start to think about like quantity frequency, pattern of use questions. The T stands for treatment. What does an individual try before? Have you ever tried a medication like methadone or buprenorphine and Naloxone, or have you done inpatient rehab IOP? Any of those things? The E stands for effects.

[00:21:07] So. How's the substance affected and an individual in a key here too, is I really like to know also, like what are the positive effects that substance has on somebody? Because again, individuals use substances for reasons, and that comes into play. When we have to develop a treatment plan. I think we really, as clinicians need to stand understand not only the negative, but also the positive effects that substances have on individuals.

[00:21:29] The A stands for abstinence, any periods of abstinence, what were you doing then? How can we help you be successful? And then R stands for relapse prevention. So like what, what steps can we start thinking about now to help, like either decrease your use? Abstinence doesn't have to be the goal. I should say that of for an individual, but how can we help keep you safe and like meet your goals of either abstinence decrease use, or just staying safe.

Addy: To summarize, when we’re trying to better understand how to treat our patients with opioid use disorder, we can use the RIP TEAR mnemonic: R stands for risk of overdose — is the patient currently in a life-threatening situation?. I stands for Initiation — when did the patient start using the substance. P is for Pattern — when and how often does a patient use opioids and what quantity do they use. T is for treatment — what treatment has the patient tried before. E is for effects — how has the substance affected the person. A is for Abstinence — have there been any past periods of successfully stopping using opioids? And lastly R — relapse prevention. How can we keep our patients safe while helping them achieve their individual goals, whether that be abstinence, decreased use, or just staying safe.

Nate: Thanks Addy, and I think you bring up a really good point of identifying that some of our patients really do not want to stop using altogether. They might just want to cut back on their use, or they might just want to continue using but in a way that minimizes their risks. So this introduces the concept of “harm reduction,” and we wanted to be sure to get our expert’s take on that. Let’s hear from Dr. Chan.

[00:30:38] So harm reduction, it's a philosophy that instead of like condemning or ignoring substance use that instead we, we work together to just like acknowledge that substance use is part of our world. And we want to do our best to keep people safe and alive. So sometimes patients don't feel like abstinence is the goal, but cutting back is likely to be safer.

[00:31:00] And, um, I just try and have patients be open and honest with what their goals are and make sure that they know when I'm not, I'm not going to kick somebody out of clinic because of a slip up. That's just not something that makes sense. Um, if there's an unexpected urine screen, the goal is to add support, to help how we can get to keep people safe.

[00:31:17] It's not to stop the medication or, or kick them out of clinic. And if a patient is like, Hey, you know, I really am motivated towards abstinence. That's my goal. Then we come up with strategies to get them there. Um, but I respect that at different times in patient's lives, abstinence may not always be the goal, but engaging them in care is still really important.

*insert music here as transition*

Addy: Asking patients the nitty gritty details about their opioid use can seem a bit risky. I think there’s this tendency among many of us to worry that we’ll ask something or make our patients talk about something that might make them want to use.

[00:05:25] Is it, um, uh, difficult when providers talk about sort of your use, um, does that induce cravings at all for you?

[00:05:34] No, not really. No, not really. Um, uh, I think it's important to talk about it. I think it's important to talk about it because the more you talk about it, I've found that. Having knowledge of what the, um, substance does to you and I know internally what it does to me, like, you know, as far as me, you know, getting high off of it, but knowing, uh, Uh, what the, uh, what the doctors tell you?

[00:06:17] I think it's important. They, you know, cause they give you a different perspective now, so it's, it's good. It's good. Then, you know, it's good to know what it really is doing to me, you know, so I can think that.

[00:06:29] what do you like about opiates?

[00:06:35] They comfort you, you get a sense of comfort. I believe. I said, in the beginning that I could be sad and I would use them. And I believe that there's a certain comfort that you get from opiates, um, makes you feel, uh everything's okay.

[00:07:04] And what don't you like about them?

[00:07:08] Uh, that I can't afford.

[00:07:12] I can't afford it's expensive to, to keep up. That's that's, that's the best, the biggie. And don't get me wrong. I'm not, you know, I'm not talking down on people, but it's the people that you have to be around to continue that type of high, it's a different crowd of people. Very different.

[00:07:42] And so I don't like that either.

Transition?

Chapter 6: Types of medication

[00:22:11]We've sort of talked about setting the tone with a patient, how to start with open-ended questions and open communication, how to elicit a good history of the rip tear mnemonic, assigning inappropriate diagnosis to a patient.

[00:22:30] but I think what I was very interested in learning more about the exciting side of addiction medicine is, uh, the treatment options. And so, uh, my first question was sort of looking at how do we treat, uh, conditions, inpatient compared to outpatient.

[00:22:52] I was just curious how you approach that because I know you work both on the floors, um, and in our clinic,

[00:22:59] I think the overall the overarching principles are the same. So it's really about meeting a patient where they're at. I will say in that in the outpatient office, patients are often coming to me being more treatment seeking and the hospital setting they're often, um, some of them are treatment seeking.

[00:23:16] Some of them are there who really want to focus on other health conditions. So I think the overarching goal is, is no matter where you're caring for a patient, the goal is to meet them where they're at and see how you can be helpful with, with their goals. There are three evidence based medications for opioid use disorder.

[00:23:32] So one is, I am so intramuscular naltrexone, which is an opioid antagonist. So it is a blocker that individuals can take. It is. Administered in a gluteal region and is good for about, about a month. The second approved medication is buprenorphine Naloxone, which is a partial opioid agonist. So I'll give, uh, I'll explain what that is a little bit more in just a bit.

[00:23:58] And then third is methadone, so that is a full opioid agonist. So when I talk to patients about that, I like to talk to. A light bulb model, because I think it's hard to conceptualize. Like what do these things even mean? So I say that if I had a light bulb, um, so the light bulb is the mu receptor and that's where the opioid acts at. Methadone is equivalent to full brightness, light bulb. I flipped on the switch all the way it is activating the receptors 100% because it's a slow activation. It doesn't have the same effect as, as a medication like heroin or fentanyl, but it acts in a very similar way. Buprenorphine Naloxone on the other hand, same light bulb.

[00:24:38] Again, same mu opioid agonist receptor, but it's partial brightness. So it's like a light bulb. That's half as bright. And that comes into play with how we start buprenorphine. But that's how I explained it to patients and naltrexone means the light bulbs just off you can't turn it on. The switch is broken it's in the trash.

[00:24:56] You will not be able to turn on that light bulb.

[00:25:00] Well, I've, I've never heard it described like that before. That's really, I think a really great way to take a really complicated topic. I mean, like, this is something that we, even as primary care providers, you know, questions ourselves, I'm like, oh, what receptor was that and what percent agonist, you know, so to be able to break that down into something as everyday, as a light bulb and explain it to patients is fantastic because really the point is, do I think engage them in their treatment decisions and really get buy-in.

Addy: Involving patients in decisions about their care is obviously just good medicine. TJ talks really beautifully about her first experience using suboxone, which is a fixed-dose combination medication of buprenorphine and naloxone.

[00:11:02] What was your initial memory of Suboxone?

[00:11:33] I didn't feel anything like, you know, I wanted to, you know, I was waiting for something. No, am I going to be high? Am I going to be sleepy? Am I God? You know, is my heart going to beat fast? You know, I was waiting for something to happen and I just felt normal. And in that way, that was really different for me.

Chapter 7: Picking which medication

Addy: You know it can be really depressing reading the news about the opioid epidemic, especially recently given all the increases in opioid use and overdoses due to COVID. However, listening to TJ’s experience with suboxone really fills me with a lot of hope. I’m so glad we have these categories of evidence-based medications that we can give patients to really make a difference in their lives.

[00:25:24] So after having kind of told us about these different categories of opioid use disorder treatment, I'm sure the question burning in everyone's mind is how do you decide which one to choose. And I know it’s a very individualized approach, but maybe walk us through a little bit about how you as the medical decision-maker along with the patient, kind of navigate those waters.

[00:25:48] Yeah, first and foremost, it's the patient's decision, you know, and fully. So patient preference is the thing that I take into consideration the most. Uh, for sure. I think there is a key piece though, to think about the feasibility of this. Just as primary care doctors. I think many of our patients face very real barriers that we have to consider. The locations where you can deliver these medicines are different buprenorphine and Naloxone, as well as IM naltrexone that can all be delivered to the primary care setting. So office-based treatment. Methadone must be delivered in an opioid treatment program. So they're called an OTP. For short. So these cannot be prescribed within the primary care setting for the treatment of opioid use disorder.

[00:26:32] It would actually be illegal for us as primary care doctors to provide methadone for opioid use disorder, we can provide it for acute pain, but it's actually illegal for us to illegal for us to do for opioid treatment program for O U D. So what that means is a patient won't have to go to a methadone clinic and at the start patients have to go every day.

[00:26:51] Does a patient have transportation? Is there a clinic by their house? Folks in different parts of the country may have challenges with access to methadone clinics here. Here we're very lucky. We're individuals can start same day Monday through Friday, not on the weekend, but Monday through Friday. Right? Um, in some places it can take weeks to months to get into a methadone treatment program. And I think that's, that's really important as well to take into consideration. Cause even if you know, a patient who really, really wants methadone, but there's no way for them to get to get to clinic every day, then that's probably not a very feasible option. I give the patients all three options, no matter what, you know, but sometimes we have to have that conversation about whether, whether that's going to be the best medication for them. I prefer buprenorphine and methadone personally. Um, the injection, I think one is challenging to initiate cause all opioids had to be completely out of one systems and that can be a challenging process and an uncomfortable process for a patient to go through. And especially in the era of fentanyl. Um, I think it can be additionally challenging to start, uh, So most my patients, my go tos tend to be buprenorphine and Naloxone or methadone, but if a patient really would like IM naltrexone, then that is okay too.

Addy: Something Dr. Chan has really been driving home is the importance of individualizing treatment for patients suffering from OUD. What might work for one patient might not for another, and decisions surrounding medication can be highly personal. In TJ’s case, for example, she tried methadone first, and it really didn’t work for her. However, when she tried suboxone, she really felt like it was a good fit.

[00:35:09] Suboxone is awesome. I tell people he saved my life. So the good thing about Suboxone is I never felt a euphoria from it, so I'm not, I don't knock anyone for, for choosing methadone. I don't, but it's no comparison to Suboxone. It's, it can’t be really can't compare it. So Suboxone, I remember when I started taking it and I told them how normal I felt.

[00:35:43] So I tell people that just give it a try. You can actually function taking suboxone. You don't have to, you don't have to worry about someone knowing that you're taking Suboxone. It's a very private medication also. That's what I like about it. All salts private medication. So when I take it, you know, and you know, I might lay down and read a book while I'm taking it or read it.

[00:36:15] You know, I read a scripture while I'm taking it or, you know, just be still, I like to be still when I'm taking. At the take it, you know what you day that's, what's great about it. It's just, you know, you just move on with your day. You know, you don't have to worry about nodding from it or, you know someone knowing that, you know, you don't have to go, sorry.

[00:36:45] I'm very sorry for saying I will stand in line and take it. You know, it’s a very private thing. You can trust it. You can, if you can, you can trust it. You can, you don't have to see this like that, that fear of going into withdrawal. Right. Uh, or are you saying that, you know, if I take this and am I going to, um, uh, am I gonna, am I gonna need a bag later or something like that?

[00:37:18] No. You’re not, you’re not. You take the Suboxone you're going to be okay. It's ends that's me. That's what makes me, it makes it makes you, it makes you actually happy, you know? Cause you know, there goes that choice, there goes that choice. Now I took my, take my Suboxone and all day long. I have choices all day long. Now once again, I'm back in the driver’s seat.

Nate: I love hearing pearls like this front patients, because I feel like so rarely do we as providers get this window into their daily routines. You can see why Suboxone works so well for TJ. It’s a private thing; And she’s made the practice of taking the medication almost meditative. Taking it in a quiet, relaxing space by herself. Reading scripture or a good book. Really associating this positive, calming environment with the medication. Now that’s not going to be everyone’s cup of tea, but I love that for her.

*music transition*

[00:37:25] So we finally figured out with our patients, which method is right for them. We've given them the options. We've used patient centered interviewing and are really bringing them in and giving them ownership of this decision about which medication and treatment plan is right for them. So say they decide on buprenorphine.

[00:37:47] How does one initiate that.

[00:37:51] That's a great question. So it's really important to remember, think back to the light bulbs we were just talking about. So buprenorphine is unique and that is a partial agonist. Partial mu agonist. So it's really important for a patient to not have opioids in their system before you start buprenorphine. So an analogy I like to use was actually developed by my colleague, Dr. Sean Cohen.

[00:38:13] So think of a car. So if you have a car that's going at a hundred miles per hour, so this is equivalent to someone who still has opioids in their system. Right? The opiods are still binding to the mu receptor, your car is going at a hundred miles per hour. If I all of a sudden give buprenorphine while that car is going at 100 miles an hour, it's like slamming on the brake because it's a partial activator and a patient's going to feel that. They're going to notice that deactivation from 100 to 50 miles per hour.

[00:38:43] Now, if you think about it, the other way around, if a patient, you know, has completely run out of gas in their tank and they're, there's no opioids on the receptors and I give them buprenorphine. Oh, wow. That person is all of a sudden, I'm going to be going at 15 miles per hour. So they're going to be feeling better and improved.

[00:38:59] So my rule of thumb is, is to wait at least 12 hours from short acting opioids. Okay. So usually I tell patients to wait till the next day I'll prescribe Clonidine 0.1 milligrams, every couple of hours, Atarax 50 milligrams, every four, six hours. Loperamide for diarrhea. that can help make things a little bit more comfortable.

[00:39:26] I let them know it's not going to be perfect, but they should hopefully help some. And then I generally tell them to start the next day. Most of my patients tend to need about 16 milligrams of buprenorphine Naloxone. So the way I prescribe it is I actually prescribed them four strips of eight milligrams.

[00:39:45] So I tell them the next day, if they're feeling like they're having opioid withdrawal and it's been at least 12 hours, take that eight milligram strip and cut it in half. So keep it in the tinfoil and just cut it and then take their first dose and put it under their tongue. Patients should know that it dissolves under your tongue.

[00:40:00] They shouldn't be eating, drinking, you know, if someone swallows it, it just, it just ain't gonna work. You know what it, how did I take it? I swallowed it. Okay. Well, Let's try it. Let's try it again. Um, so it's really important that patients know that, cause it's not, it's just not intuitive. It's not intuitive.

[00:40:15] And if it, if they do okay with that dose, I tell them they can take the other four in about an hour. Um, if mid day, if they're still having some cravings or thoughts or aren't feeling good to just take the other eight. So that.

[00:40:27] way, the first day they can really take up to about 16 milligrams. Um, they can dose it a little bit differently as well if they, if they want to take that second aid and cut in half, that is okay as well.

[00:40:38] And then the next day, I say, generally just continue the 16 milligram.

*Music transition*

Fentanyl has really complicated this process. I don't want people to be afraid of this, but fentanyl is very lipophilic and at least in the Northeast, um, a lot of our heroin isn't really heroin and it's actually fentanyl. So fentanyl is very lipophilic.

[00:40:59] So it stores in your fat cells. So even though we know fentanyl is short acting, right, this is why we use it in the ICU and surgeries, Repeated use over a long period of time, um, actually makes it sort of act like a little bit of a longer acting opioid again, cause it's staying in your plasma and your fat cells and sort of like excluding back out into the plasma.

[00:41:18] So for patients who have extensive fentanyl user fentanyl exposure. Usually I tell them to wait closer to 24 hours to try and minimize the risk of precipitated withdrawal. Because again, the idea is, is we really want most of the opiates to be at the system before we start the buprenorphine. If not, there's a chance that it could make somebody feel worse.

Nate: I’m loving this, so much great learning here, let’s take a step back and let it sink in. To summarize, there are three drugs approved by the FDA to treat opioid use disorder. The first is methadone, which is a long-acting, full opioid receptor agonist. In the U.S., it’s currently illegal for primary care doctors to prescribe methadone for opioid use disorder, meaning patients need to frequently travel to their local methadone clinic to receive treatment. Second is buprenorphine, which we’ve heard a lot about today from Dr. Chan. Third is naltrexone, which is an opioid antagonist. The long-acting injectable form, Vivitrol, is administered intramuscularly in the gluteal region and lasts for approximately one month.

We frequently prescribe and administer these last two medications in our addiction recovery clinic, which some of you out there will remember that we like to refer to by its acronym, “ARC.” This clinic has been not only invaluable for us trainees, but, more importantly, for our patients as well. We wanted to give Dr. Chan the opportunity to tell you all a bit more about what makes it so special and how you might be able to incorporate the model into your own practice.

Chapter 8: How PCPs can start prescribing OUD medication

[00:34:08] Describe briefly our recovery addiction clinic, your experience working in it, um, and maybe other, um, addiction clinic models that you've seen, um, either things that have worked for patients, things that haven't worked, or just, uh, your thoughts on dedicated, uh, programs like this.

[00:34:41] The we call it the ARC clinic here. It's great. It's an addiction recovery clinic. That's centered in primary care. It's wonderful. So we, we have a lot of internal referrals, so we are at a federally qualified health center. So individuals sort of within the practice can refer patients internally to come to that clinic to get expertise.

[00:35:03] And some patients just need more frequent follow-up and. Maybe the bandwidth isn't there. And we can also connect patients to other services such as our group visits, which is like a really lovely model. But also I want to say that, like, anybody can do this in primary care. I want you to feel empowered to say, yes, I can do this.

[00:35:20] I don't need a specialty clinic. Maybe I need some support, but there are tons of resources out there such as PCSS. Or ACM and folks who can guide you. It's great to have that dedicated clinic space, but that's not necessarily necessary. Another common model of, of addiction treatment is, is the hub and spoke model.

[00:35:40] So addiction treatment centers will stabilize a patient. Buprenorphine that after a period of time where the patient is stable, they will then transfer that patient to their primary care doctor. So visits are spaced out and refills are given et cetera, because again, it's a chronic disease, right? If someone's high blood pressure is under control, you get to space out visits, right?

[00:36:01] The medication often stays the same, the same principles apply here.

Nate: But as many of us know, there are some special rules surrounding Suboxone – who can prescribe it, additional training that’s sometimes needed, etc. And that can be a big barrier for many providers who want to use this medication in their practices. Of course we want to help our patients with opioid use disorder, and we’ve heard great things about buprenorphine, but until we get credentialed, that doesn’t help anyone. So where should we as primary care providers begin?

[00:53:18] For any primary care doctor who would like to treat. Patients with medications like buprenorphine and Naloxone, it starts with one patient. You know, it doesn't have to be this, this extraordinarily complicated clinic structure. It really just starts with one patient. So I really encourage all primary care doctors to become.

[00:53:39] Um, approved to prescribe this medication. So the way you do it now, there have been some updates and the regulations. So now physicians who would like to prescribe for up to 30 patients need to submit a notice of intent to the DEA. So additional training isn't even needed anymore for up to 30 patients.

[00:53:57] If you want to prescribe above that, um, training is still needed, but it's really simple to do at this time. So I really encourage you to do it. One because you never know if a patient will need it. Right. You never know what their access is. So even if you're like, I dunno if I would do this for forever, just that just having the ability to do so in an emergency or in a situation I think is important for all of us, because the only way for us to really, Um,

[00:54:22] as a field, I think to help address, you know, this, this crisis, you know what this is now like the fourth wave of the, of the opioid epidemic. we really have to bring addiction treatment within to primary care.

[00:54:37] Yeah.

[00:54:37] I love that, you know, it all starts with just one step. Right. And it all starts with just one patient. I think that's so powerful.

Nate: It really is powerful. Putting in that activation energy, just getting started — knowing that that’s sometimes the hardest part can be reassuring for providers. And for those of us who are in that boat of just beginning to see patients with opioid use disorder, we’d like to leave you with some parting advice from our patient TJ.

[00:38:50] How about people treating you like either residents or young, young doctors. Is there anything that you think might be helpful about your experience for them to know?

[00:39:00] Not to put everyone in the same category, know that each person has different. The medication is going to bring that person out.

[00:39:14] It's going to bring them out,

[00:39:32] You know, each person is going to be okay. When you coming from a rich background, you're coming from a poor background. Uh, you know, it doesn't matter because they'll be okay just then just let them know that they're going to be okay. And be gentle and be gentle because they've been through a lot. By the time that they come for help, they've been through hell.

[00:39:57] It's hard to come for help. So when you finally, when they finally come for help, be gentle, let them know, let them know they’re going to be alright.

[00:40:08]

Nate: After my first year of medical school, I did a one-week Summer Institute for Medical Students at the Betty Ford Center in Southern California. It was this really unique experience where we participants were immersed with patients and their clinicians to see just how this whole rehab thing worked, right? It was an amazing opportunity that I learned so much from. And I remember then, and I guess this dates me a bit, that the Center had only just started to use medications like Suboxone as part of their treatment for opioid use disorder. And believe it or not, this was a really controversial switch at the time, because so many people embedded in the history of the Center were invested in this idea of 12-step programs alone being enough.

Now, I think we’re lucky enough to understand that opioid use disorder is a biopsychosocial disease, and for many patients, medication will be a key component in their robust, individualized, evidence-based strategy for treatment and relapse prevention. And this is not to say that 12-step programs aren’t powerful or still a cornerstone of treatment, because they are, and we’ll get into that more in the final episode of this series. But today, I’m happy that we’ve been able to shed some light on how to use medications for opioid use disorder, not only from our perspective as the provider, but also from the perspective of the patient. And I’d like to thank TJ for sharing that with us.

Here are some key takeaways that I took from today’s episode and hope you can too:

In order to decide which medication is best for a patient with opioid use disorder, we need to start by taking a good history. For this, we like the mnemonic RIP-TEAR. R = risk of overdose. I = Initiation of use. P = Pattern of use. T = treatments previously tried. E = effects of the substance on the patient. A = Abstinence — how long, and when, if ever? And R — Relapse prevention.
There are three FDA-approved medications for the treatment of opioid use disorder: One is methadone, a full opioid receptor agonist that patients can get from a designated methadone clinic. Another is buprenorphine, also called Suboxone, a partial opioid receptor agonist that can be prescribed in the primary care clinic. And then there’s naltrexone, an opioid receptor antagonist that can be injected intramuscularly and can last approximately one month. Deciding which medication to choose for which patient will depend on a variety of biopsychosocial factors, including the information you get from the RIP-TEAR history, any potential barriers, and patient preference.
As providers, we have a moral obligation to provide treatment to our patients with opioid use disorder. One component of that treatment is medication. While referring patients for treatment is one option, actually prescribing these medications ourselves can be both impactful and fulfilling. Thankfully, getting approval to prescribe buprenorphine-naltrexone is becoming easier, with that new option of sending a notification of intent — which is really just an online form that you fill out — to the Substance Abuse and Mental Health Services Administration. And, good news — you’ve already taken the first step by spending some time learning with us today! We’re glad you joined us.

Addy: Be sure to tune in next time wherever you listen to your podcasts to catch part III of the OUD series, where we’ll be discussing group therapy and counseling, sponsors, and relapses.

We hope you enjoyed this episode which was made possible by contributions from our patient TJ, our resident interviewer, Dr. Mariah Everts, and Dr. Caroline Chan, who provided faculty peer-review for the project and served as our expert. Special thanks to our producers Dr. Joshua Onyango, Helen Cai, and Dr. Mariah Evarts, as well as our faculty advisor Dr. Katie Gielissen.Be sure to follow us @pcpearls on instagram where you can expect to get sneak-peeks, additional learning content, and the most up-to-date details on show release times.

Nate: And don't forget, you can head to our link tree@linktree.com slash PC pearls and click on, send us a voice message to send us your questions, reflections and personal experiences. We'd love to hear from you. And if you could please leave us a rating and a review. Don't forget to subscribe to primary care pearls, wherever you get your podcasts so that you can stay up to date on new episode release.

Addy: And if you enjoyed this episode, please share it with a friend or colleague who would be interested to learn about the health issue we discussed today.

Thanks again for joining us today. Farewell from all of here us at the Primary Care Pearls podcast, and we’ll catch you in the next one.

Nate: ‘til next time!