Office-based Treatment Research Articles

A Primary Care Response to COVID-19 for Patients with an Opioid Use Disorder.

A Primary Care Response to COVID-19 for Patients with an Opioid Use Disorder.

Management of Opioid Misuse and Opioid Use Disorders Among Youth.

In response to the growing impact of the current opioid public health crisis in the United States on adolescents and young adults, pediatricians have an expanding role in identifying opioid use early, preventing escalation of risky use, reducing opioid-related harms, and delivering effective therapies. Research and expert consensus suggest the use of brief interventions focused on reducing risks associated with ongoing opioid use and using motivational interviewing strategies to engage youth in treatment. Because fatal opioid overdose remains a major cause of opioid-related mortality among youth, delivering overdose education as part of any visit in which a youth endorses opioid use is one evidence-based strategy to decrease the burden of opioid-related mortality. For youth that are injecting opioids, safe injection practices and linkage to needle or syringe exchanges should be considered to reduce complications from injection drug use. It is crucial that youth be offered treatment at the time of diagnosis of an opioid use disorder (OUD), including medications, behavioral interventions, and/or referral to mutual support groups. The 2 medications commonly used for office-based OUD treatment in adolescents are extended-release naltrexone (opioid antagonist) and buprenorphine (partial opioid agonist), although there is a significant treatment gap in prescribing these medications to youth, especially adolescents <18 years of age. Addiction is a pediatric disease that pediatricians and adolescent medicine physicians are uniquely poised to manage, given their expertise in longitudinal, preventive, and family- and patient-centered care. Growing evidence supports the need for integration of OUD treatment into primary care.

Identification and Management of Opioid Use Disorder in Primary Care: an Update.

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

MP25-08 FIRST-IN-HUMAN CLINICAL EXPERIENCE WITH THE XFLO EXPANDER SYSTEM TO TREAT LOWER URINARY TRACT SYMPTOMS SECONDARY TO BENIGN PROSTATIC HYPERPLASIA

INTRODUCTION AND OBJECTIVE:The XFLO Expander system is a new, office-based treatment for men suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The ...

DEA, SAMHSA relax OTP/OBOT regulations due to COVID‐19

Opioid treatment programs (OTPs) that dispense methadone got a fast and clear reprieve from federal authorities last week in the face of COVID‐19. The Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) issued policies that give OTPs flexibility in take‐homes, limiting the frequency of face‐to‐face contact and opportunities for transmission of COVID‐19. There is also greater flexibility for office‐based opioid treatment (OBOT) with buprenorphine.

Psychosocial Interventions in Office-Based Opioid Treatment: A Systematic Review

AbstractObjective: Medication-assisted treatment (MAT) in office-based opioid treatment (OBOT) is expanding treatment of opioid use to primary care settings. OBOT combines MAT and behavioral health...

CHIVA to Treat Saphenous Vein Insufficiency in Chronic Venous Disease: Characteristics and Results

There is considerable debate in the literature with relation to the best method to treat patients with chronic venous disease (CVD). CHIVA is an office-based treatment for varicose veins performed under local anesthesia. The aim of the technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease. This paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than stripping saphenectomy. The main advantages are preservation of the saphenous vein, local anesthesia, low recurrence rates, low cost, low pain, and no nerve damage. The major disadvantages are the learning curve and the need to train the team in venous hemodynamics.

A review of the treatment of anisometropic amblyopia in adults using dichoptic therapy

Background: In recent years, it has been established that the suppression of the amblyopic eye by the fellow eye is the major cause of amblyopia. New behavioural therapies like dichoptic therapy attempt to reduce suppression in amblyopic adults who have passed the critical stage of visual cortex development. Anisometropic amblyopia has the highest prevalence of amblyopia, and managing this condition in adults may lead to improvement in the quality of life. Aim: The purpose of the review is to assess the impact of this novel treatment of amblyopia, with particular focus on using dichoptic therapy for anisometropic amblyopia in adults. Methods: A literature search was conducted on articles published in the last 20 years, and papers were sourced from databases such as Elsevier, Science Direct and PubMed using the reference manager Mendeley. (The search was performed from December 2017 to December 2018.) Results: Evidence from located studies in adults with anisometropic or mixed amblyopia managed with new behavioural treatments including dichoptic therapy showed some significant improvement in the best-corrected distance visual acuity, stereopsis and contrast sensitivity whilst improving or restoring optimal binocular vision. Conclusion: Adults with anisometropic and/or mixed amblyopia can benefit from dichoptic therapy with a unique approach to improve binocularity concurrently. The therapy represents a viable option for managing amblyopia in adults and can be administered as office-based or home-based treatment in a timely manner that could improve the quality of life for such patients.

Impact of Office-based Opioid Treatment on Emergency Visits and Hospitalization in Adolescents with Opioid Use Disorder

To determine if engagement in office-based opioid treatment decreases emergency department, urgent care visits, and hospitalizations for acute opioid-related events (OREs) among adolescents with opioid use disorder. This retrospective cohort study identified all emergent and outpatient visits among adolescents, age 10-19 years, referred for office-based opioid treatment between January 1, 2006 and December 31, 2016. Patients were dichotomized into 2 cohorts: those who did and did not engage in office-based opioid treatment. The primary end point was the difference in the proportion of visits over the study period for acute OREs between cohorts and within the office-based opioid treatment cohort before and after referral. Secondary end points assessed change in the proportion of outpatient visits for treatment unrelated to opioid use disorder. Four hundred five emergent and outpatient visits were identified: 285 (70.4%) in the office-based opioid treatment cohort and 120 (29.6%) in the non-office-based opioid treatment cohort. After office-based opioid treatment engagement, 27.8% of visits in the office-based opioid treatment cohort were for acute OREs vs 80.8% in the non-office-based opioid treatment cohort (OR, 0.092; 95% CI, 0.052-0.160; P<.001). Outpatient visits in the office-based opioid treatment cohort were 10.9 times that of non-office-based opioid treatment (OR, 10.9; 95% CI, 6.23-19.16; P<.001). Within the office-based opioid treatment cohort, emergent visits decreased from 76.1% to 27.8% (OR, 0.121; 95% CI, 0.070-0.210; P<.001) and the odds of outpatient services was 8.3 times more after engagement (OR, 8.27; 95% CI, 4.78-14.4, P<.001). The absolute decrease in emergent visits for acute OREs was 53% in adolescents engaged in office-based opioid treatment, representing a relative decrease of 65.6% compared with adolescents not engaged. An analysis of visits before and after office-based opioid treatment demonstrated similar decreases, suggesting that office-based opioid treatment has a significant impact in decreasing acute OREs in the adolescent population.

2020 Annual Meeting Course Section: Why a Course?

Back to table of contents Next article APA & MeetingsFull Access2020 Annual Meeting Course Section: Why a Course?Catherine Crone, M.D.Catherine CroneSearch for more papers by this author, M.D.Published Online:10 Jan 2020https://doi.org/10.1176/appi.pn.2020.1b50AbstractWant an option for an intensive learning experience? Don’t want to fight the crowds when you head to a popular talk by a national or international expert? Want a chance to ask more than one brief question at the end of one of the many general sessions? Want an opportunity to talk to an expert, learn a new skill, or sharpen your current skills with the latest information? If you answer “yes” to any of these questions, then consider taking a course at APA’s Annual Meeting! These are four-hour, in-depth offerings on a wide variety of subjects including psychotherapy, cannabis, neuropsychiatry, global mental health, technology, forensic psychiatry, transcranial magnetic stimulation, and public speaking.Want something more? Try a master course, an eight-hour intensive learning experience that will hone your skills in areas such as psychopharmacology, motivation interviewing, suicide assessment, management of first-episode psychosis, and office-based buprenorphine treatment. Each of these includes receipt of an APPI-published book on the course’s topic by the experts teaching the master courses.Due to their popularity, courses fill fast, so don’t delay. Register for the Annual Meeting today and be sure to get a seat in your first-choice courses. ■Download the 2020 Annual Meeting Course Guide.Catherine Crone, M.D., is the vice chair in the Department of Psychiatry and Behavioral Sciences at Inova Fairfax Hospital. She is also a member of the Scientific Program Committee. ISSUES NewArchived

Office-Based Buprenorphine Treatment: Identifying Factors That Promote Retention in Opioid-Dependent Patients.

Opiate addiction is a serious global health issue that profoundly impacts the welfare of populations around the world. Opioid addiction affects an estimated 1.9 million individuals in the United States alone, stimulating a rise in treatment options such as medication-assisted treatment with buprenorphine. When combined with counseling and relapse prevention groups, medication-assisted treatment has proven to be an effective office-based opioid treatment for opiate dependence. Office-based opioid treatment has broadened access to treatment of opioid dependence, has decreased the risk for overdose, and is effective for reducing cravings and opioid use at proper dosing levels. However, treatment retention and relapse remain significant challenges. The purpose of this study was to identify characteristics predictive of retention in treatment time of opioid-dependent individuals receiving office-based buprenorphine treatment. The records of individuals enrolled in a public health office buprenorphine clinic (n = 350) were analyzed to determine retention time in treatment and whether retention time varied by selected individual variables. Participants in the study had a cumulative predicted retention time on buprenorphine of 65% at 30 days, 35% at 6 months, 25% at 12 months, and 18% at 18 months.

An Innovative Model for Implementing Office-Based Opioid Treatment in Community-Based Settings

This report describes an innovative approach to implementing the Office-Based Opioid Treatment (OBOT) model in underserved, community-based settings. Although numerous resources are available to physicians interested in offering medication-assisted treatment (MAT), there is little guidance on how to integrate and operationalize OBOT models in community health centers.

A Financial Model for Team-Based Opioid Use Disorder Treatment.

Opioid use disorder (OUD) affects 2 million Americans, yet many patients do not receive treatment. Lack of team-based care is a common barrier for office-based opioid treatment (OBOT). In 2015, we started OBOT in a family medicine practice. Based on our experiences, we developed a financial model for hiring a team member to provide nonbillable OBOT services through revenue from increased patient volume. We completed a retrospective chart review from July 2015 to December 2016 to determine the average difference in medical visits per patient per month pre-OBOT versus post-OBOT. Secondary outcomes were the percentage of visits coded as a Level 3, Level 4, and Level 5, and the percentage of patients with Medicaid, private insurance, or self pay. With this information, we extrapolated to build a financial model to hire a team member to support OBOT. Twenty-three patients received OBOT during the study period. There was a net increase of 1.93 visits per patient per month (P < .001). Fourteen patients were insured by Medicaid, 7 had private insurance, and 2 were self pay. Twenty-three percent of OBOT visits were Level 3, 69% were Level 4, and 8% were Level 5. Assuming all visits were reimbursed by Medicaid and accounting for 20% cost of business, treating 1 existing patient for 1 year would generate $1,439. Treating 1 new patient would generate $1,677. In a fee-for-service model, the revenue generated from increased medical visits can offset the cost of hiring a team member to support nonbillable OBOT services.

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice

BackgroundThe integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices.MethodsA novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes.ResultsTwelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9–15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD.ConclusionsOBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

BackgroundGroup-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical “how to” components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment?MethodsTo create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish “core” and “malleable” components, and provide a conceptual framework for considering various options for implementing the malleable components.ResultsWe identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions.ConclusionWhile further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

780. Inpatient Addiction Medicine Consultations at the Urban/Rural Frontier: Improving Quality of Care and Linkage to Outpatient Services for Patients with Substance Use Disorder in Central Kentucky

BackgroundWhen persons with opioid use disorder (OUD) are hospitalized with medical complications (e,g. endocarditis, viral hepatitis) they frequently do not receive medications for the underlying OUD. In recent years, a number of hospitals have implemented addiction medicine consultation (AMC) services to help address this treatment gap, though these are all in large urban centers. AMCs provide comprehensive substance use disorder (SUD) assessments, manage SUDs, initiate pharmacotherapy for OUD, and arrange linkage to ongoing treatment. The aim of this study was to describe the initial implementation and outcomes of a new AMC at the University of Kentucky Hospital, a 945-bed tertiary referral center with a large rural catchment.MethodsThe Addiction Consultation and Education Service(ACES) began October, 2018 and was comprised of several physicians and an APRN. A patient navigator assisted with prior authorizations and outpatient linkage. ACES referred to a new bridge clinic at the University for ongoing office-based opioid treatment as well as to community programs and licensed opioid treatment programs. Patient demographics, SUD diagnoses, and comorbidities (including details of the injection-related infections) are collected from the electronic health record, as well as key process metrics including: time-to-consultation and medication initiation, length of stay(LOS), discharge against medical advice(AMA), and details of linkage to outpatient services.ResultsFrom October-December, 91 patients were seen, 73 met DSM-5 criteria for OUD, 82 had a medical complication of SUD, and 53 lived in rural counties (Rural-Urban Continuum Codes 4–9). Average LOS was 19.5 days. Among OUD patients, 71% underwent buprenorphine/naloxone induction, 9% were started on methadone. Less than 6% of patients started on buprenorphine or methadone left against medical advice.ConclusionAMCs are a key part of providing comprehensive care for persons hospitalized with infectious complications of substance use. Initiating medication for OUD likely decreases rates of discharge against medical advice. Compared with other AMCs, a greater percentage of patients seen by ACES resided in rural counties. Establishing a bridge clinic prior to starting an AMC is critical to ensure ongoing care.Disclosures All authors: No reported disclosures.

Perspectives on the HIV continuum of care among adult opioid users in New York City: a qualitative study

BackgroundEngagement in the HIV care continuum combined with office-based opioid treatment remains a cornerstone in addressing the intertwined epidemics of opioid use disorder (OUD) and HIV/AIDS. Factors influencing patient engagement with OUD and HIV care are complex and require further study.MethodsIn this qualitative study, in-depth interviews were conducted among 23 adult patients who use drugs (PWUD) in an inpatient detoxification program in New York City. The semi-structured interview guide elicited participant experiences with various phases of the HIV care continuum, including factors influencing access to HIV care, interactions with HIV and primary care providers, preferences around integrated care approaches for OUD and HIV, and barriers experienced beyond clinical settings which affected access to HIV care (e.g., insurance issues, transportation, cost, retrieving prescriptions from their pharmacy). Data collection and thematic analysis took place concurrently using an iterative process-based established qualitative research method.ResultsRespondents elicited high acceptability for integrated or co-located care for HIV and OUD in primary care. Factors influencing engagement in HIV care included (1) access to rapid point-of-care HIV testing and counseling services, (2) insurance coverage and costs related to HIV testing and receipt of antiretroviral therapy (ART), (3) primary care providers offering HIV care and buprenorphine, (4) illicit ART sales to pharmacies, (5) disruption in supplies of ART following admissions to inpatient detoxification or residential treatment programs, (6) in-person and telephone contact with peer support networks and clinic staff, (7) stigma, and (8) access to administrative support in primary care to facilitate reengagement with care following relapse, behavioral health services, transportation vouchers, and relocation from subsidized housing exposing patients to actively using peers.ConclusionThese findings suggest expanding clinical and administrative support in primary care for PWUDs with patient navigators, case managers, mobile health interventions, and peer support networks to promote linkage and retention in care.

Stigma, Misunderstanding Among the Barriers to MAT Treatment

Stigma, Misunderstanding Among the Barriers to MAT Treatment

Acute lacerations: Assessment and non-surgical management.

Given appropriate case selection and capability, many acute lacerations can be managed in the primary care setting. An understanding of the basic pathophysiology, assessment and management principles is essential. The aim of this article is to provide a basic framework for assessing and managing simple acute lacerations. The aim of assessment is initially to decide whether the laceration is suitable for office-based treatment, and then whether it requires formal surgical closure with sutures or staples. Two non-surgical techniques for skin closure in amenable wounds are described. A companion article in this issue provides details of surgical closure techniques and wound aftercare.

Patient Barriers and Facilitators to Medications for Opioid Use Disorder in Primary Care

Introduction: This study explored factors influencing patient access to medications for opioid use disorder (OUD), particularly for individuals eligible but historically suboptimal follow-up with in-house referrals to office-based opioid treatment (OBOT). Objectives: In-depth qualitative interviews among a mostly underserved sample of adults with OUD elicited: 1) knowledge and experiences across the OUD treatment cascade; and 2) more nuanced elements of patient-centered care, including shared decision making with providers, experiences in OBOT versus specialty addiction treatment, transitioning from methadone to buprenorphine or extended-release naltrexone (XR-NTX), and voluntary discontinuation of medications for OUD. Methods: We conducted semi-structured qualitative interviews between January and February of 2018 among adult inpatient detoxification program patients with OUD (n = 23). Preliminary analysis of interviews yielded key themes and ideas that were coded from a grounded theory approach. Results: Willingness to engage with OBOT was influenced by a complex array of practical considerations, including access to patient-centered care in OBOT settings, positive experiences with illicitly obtained buprenorphine, and differential experiences pertaining to OBOT versus specialty addiction treatment. Responses were generally favorable towards OBOT with buprenorphine, yet knowledge regarding extended-release naltrexone was limited. Respondents were often frustrated by clinicians when requesting to transition from methadone to buprenorphine or XR-NTX. Lastly, participants elucidated limited access to OBOT programs in underserved neighborhoods and suburban settings. Conclusion: Limited access to patient-centered care in OBOT with buprenorphine and extended-release naltrexone may exacerbate challenges to retention and/or reengagement with OUD care.