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  • Contingency Management in General Treatment Populations and Special Groups (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    Contingency management (CM) is a powerful treatment approach with strong empirical support and large effects, but which is underutilized in community treatment. This workshop will provide information and interactive experience to explore the barriers to CM use and encourage implementation of practical, cost-effective techniques.

    Contingency management (CM) is a powerful treatment approach which is underutilized in community treatment but forms the basis of some of the most successful treatment approaches in special populations such as physicians and drug courts. This workshop will draw on the successes of CM methods in these special populations while exploring barriers to CM use in general treatment populations. Contents and Methods: (1) Background. David Lott will present background information including an overview of the behavioral principles that guide CM approaches, a synopsis of the large body of CM research demonstrating its effectiveness, and highlights of experiences with CM methods in various settings. (2) Special Populations. Danesh Alam will describe treatment in physician health programs with monitoring and high success rates, make connections to the CM theoretical principles, and draw conclusions for improving use of these same principles in other treatment settings. (3) Implementing a CM Program in community treatment. David Lott will describe the process of choosing a CM approach and starting it in the adolescent treatment program at Linden Oaks Addiction Treatment Programs and present data showing the impact of this CM program on financial, staff, and patient outcomes. (4) Questions and Discussion. This session will provide valuable training by helping participants learn a powerful but underutilized treatment approach. Through didactics and discussion, attendees will learn the rationale and methods of contingency management and address the challenges often faced during implementation of a CM program.

    David C. Lott

    MD, DFAPA, DFASAM

    Dr. Lott is Medical Director of Addiction Services at Linden Oaks at Edward-Elmhurst Healthcare in Naperville, Illinois where he is an active clinician and helps direct residential, inpatient, and other treatment services. He is a Clinical Assistant Professor of Psychiatry at the University of Illinois at Chicago and remains active in research and teaching residents and other trainees. He is a Distinguished Fellow of the American Psychiatric Association and the American Society of Addiction Medicine and currently serves as Treasurer of the Illinois Society of Addiction Medicine. He received his undergraduate degree from Duke University and his medical degree from Johns Hopkins. He then completed a residency in Psychiatry at The University of Chicago and a Fellowship in Addiction Psychiatry at The University of Illinois at Chicago, and he is board certified in Addiction Psychiatry and Addiction Medicine. He has published several research articles in areas including opioid addiction, genetics, and contingency management. Finally, Dr. Lott is a past recipient of the ASAM Ruth Fox Endowment Fund Scholarship and the American Academy of Addiction Psychiatry Research Award.

    Danesh Alam

    MD, DFAPA, FASAM

    Danesh Alam, MD, DFAPA, FASAM is the Medical Director of the Northwestern Medicine Central Dupage Hospital.

  • Methadone & Long QTc: Clinical Prediction, 5-Year Prevalence, and Causes-Interventions (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    The goal of the session is the prevention and early intervention of long QTc in patients receiving methadone maintenance treatment (MTT). The presentations are based on observations made over a five-year period in a MMT program. These observations range across a novel clinical biomarker, epidemiological observations made over 300 patient-years, along with clinical diagnosis, intervention, and outcome. We will engage our participants such that they can apply our findings to their clinical populations receiving MMT.

    The goal of the session is the prevention and early intervention of long QTc in patients receiving methadone maintenance treatment (MTT). The presentations are based on observations made over a five-year period in a MMT program. These observations range across a novel clinical biomarker, epidemiological observations made over 300 patient-years, along with clinical diagnosis, intervention, and outcome. We will engage our participants such that they can apply our findings to their clinical populations receiving MMT. The first presentation by Dr. Scott McNairy explains our efforts at identifying a readily available methadone parameter than might show an association with QTc duration. Of seven methadone parameters studied, one parameter (the ratio of methadone dose to body weight) showed a moderate correlation with QTc duration at high significance (p < .001). We assessed this parameter due to the distribution of methadone in body fat as well as its concentration in numerous organs (heart, lung, and other organs) plus the weak, often inconsistent relationship of methadone dose to long QTc. This novel dose/weight ratio produced a high-sensitivity, low-specificity ratio that could be used for routine screening purposes, and another low-sensitivity, high-specificity ratio that could be used in urgent/emergent clinical settings for MMT patents presenting with symptoms suspicious for long QTc (i.e., palpitations, slow or fast pulse, abnormal rhythm, chest discomfort, weakness, fatigue). Use of these ratios might help with individualizing the expert panel recommendations that MMT patents receive regular EKG tests to assess for long QTc. Second, Dr. Gihyun Yoon presents epidemiological data on the prevalence and recurrence of long QTc among 69 patients during 300 patient-years of observation. Long QTc occurred in 32% of MMT patients during the 5-year period. In addition, about 58% of patients who had one long QTc episode were prone to a second or a third recurrent episode. These episodes ranged from asymptomatic (67%) to symptomatic (33%), including two cases of torsade de pointes. Third, Dr. Joseph Westermeyer focuses on the causes of long QTc. Causes were identified based on interventions that successfully returned the QTc to normal. Three general categories were identified, consisting of (1) prescribing decisions involving particular medication groups, (2) re-addiction with opioids and benzodiazepines, and (3) certain conditions affecting metabolism (i.e., renal insufficiency, dehydration, sudden weigh loss, post-childbirth). Recurrences can involve the same of difference causes. Cause could not be determined in two patients, who recovered spontaneously. One mortality occurred in an asymptomatic patient who refused to consider a methadone dose reduction and died suddenly six months later. At the beginning of the presentation, Dr. Heather Swanson will lead a group exercise in which audience members consider common clinical problems. Audience members will report their clinical decisions, followed by a question-and-answer period. At the conclusion of all three sessions, a panel of the three discussants will be convened to consider how the information and conclusions from all three sessions might be integrated and applied in MMT programs. Dr. Patricia Dickmann will chair this panel-audience interaction.

    Joseph Westermyer

    MD, PhD, MPH

    Joe Westermeyer has worked in methadone programs since serving in one of the initial VA methadone programs in the mid-1970s.  Subsequently he served as a consultant to the World Health Organization.  The latter role involved aiding countries identify the nature and extent of opioid and other substance disorders,  undertake broad-based approaches to prevention and early intervention, and  (as appropriate) consider treatment and rehabilitation programs.  Such programs included utilizing methadone treatment in various ways, including short- and long-term withdrawal regimens, as well as short- and long-term maintenance methods (as described in an edited book by Arif and Westermeyer).  His recent work in this area grows out of intensive observation and clinical work with a group of methadone maintenance patients over several years.
    This most recent work depends on longitudinal observation and study over a long time, with repeated use of methadone blood levels (trough and 3-hour peaks) and electrocardiographs.  He collaborated with cardiologists Drs. Adabag and Anand in obtaining hand-measured QT intervals and comparing them with computer-derived QT intervals.  These data were obtained both routinely (upon induction and then annually) and as warranted when clinical symptoms or disability arose.  This work builds on original basic work done with methadone decades ago, but then abandoned – with many clinical questions unanswered. 

    Patricia Dickmann

    MD

    Patricia Dickmann MD is a staff psychiatrist at the Minneapolis VA Medical Center. She splits her time between addiction psychiatry, a clinic for homeless vets, teaching, and research. She serves as the Medical Director of the Minneapolis VA's Opioid Treatment Program. Dr. Dickmann is also the Minneapolis VA's Psychiatry Residency Site Director. She is involved in several research projects, two involving neuromodulation (tDCS, tMS). 

    Gihyun Yoon

    MD

    Dr. Yoon is a staff psychiatrist at the VA Connecticut Healthcare System and an Assistant Professor in the Department of Psychiatry at Yale University School of Medicine. His research interests include (1) pharmacotherapy for addictive disorders (especially alcohol use disorder) and (2) pharmacotherapy for psychiatric disorders (especially major depressive disorder).

    Scott McNairy

    MD, FASAM

    Scott has 36 years experience in the delivery of clinical health care focused on treatment for chronic pain, addictive and combat stress disorders. He is Board Certified in the Addiction Psychiatry. His post-graduate training in psychiatric medicine began at the Mayo Clinic 1975-1979. He is most indebted to early Mayo consultants for pioneering novel addiction and pain medicine treatment practices which serve as a foundation for his practice at the VA today. . Scott was an early board member for Minneapolis Pathways, one of the first health crisis resource centers for life-threatening medical illness in the country. Many of those practices are now well–integrated in to treatment for palliative and end of life care. He champions greater use of addiction pharmacotherapy in primary care and psychiatry and trains physicians for the DEA buprenorphine waivered licensure. He is using  utilization of pharmacy data mining for monitoring treatment outcomes that will enhance patient safety and evidence-based care.His clinical outcome studies include 1) development of a medication management support group for opioid dependent patients treated with buprenorphine to promote treatment success and 2) the use of parenteral depot naltrexone for high medical risk, chronic and treatment refractory alcohol dependent veterans which dramatically reduces overall costs of care and disease progression.At the University of Minnesota - VA campus he directs the fellowship in addiction psychiatry and site directs the ABAM addiction medicine fellowship  recognized by ABMS.  He is recognized for his excellence in teaching and modeling positive clinical encounters. He places primary emphasis on restoration of function and prevention of deterioration as outcomes for success. Scott is an integral part of a treatment team comprised of physicians, nurses, social workers and psychologists without whom he could not have achieved the success that he has had.

  • Together at Last - Addiction Medicine Joins Primary Care and Behavioral Health (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    The integration of three disciplines, addiction medicine, primary care, and behavioral health, is essential to optimizing care for the substance use disorder patient. This presentation describes the addition of addiction medicine into an already integrated primary care-behavioral health federally qualified health center. The discussion will include concept formation, staff development, implementation, and a review of early effectiveness data.

    The overwhelming prevalence of binge drinking, 66.7 million Americans in the past thirty days, heavy alcohol use, 17.3 million in the past month, and illicit substance use, 27.1 million users in the past thirty days, requires an integrated and comprehensive approach on the part of clinicians to address this public health crisis. The recognized disproportionately high prevalence of co-morbid psychiatric and medical illnesses in the substance use disorder population further demands a consolidated treatment strategy to care for these patients. Cherokee Health Systems (CHS), a large, multi-center FQHC long a leader in behavioral health and primary care integration, has embarked on an ambitious program of graduated introduction of addiction medicine services into every day clinical practice for all medical (including obstetrics) and behavioral health providers. This CHS program integrates addiction medicine services at the level of the primary care provider and behavioral health consultant using screening, brief intervention, and referral to treatment (SBIRT) tools consistent with ASAM Level 0.5 care; provides for medication assisted treatment, office based opioid treatment, intensive outpatient treatment programs, and, ultimately, a partial hospitalization program delivered by an addiction medicine specialist, psychiatrists, and psychologists consistent with ASAM levels 2.1 and 2.5 care; through to an innovative, integrated complex care team comprised of an addiction medicine specialist, primary care providers, obstetricians, psychologists, nurses, community health coordinators, and administrative staff all working together with team-based patient encounters to provide services to pregnant women and the most seriously ill, high co-morbid disease burden patients. Staff required training regarding the disease model of addiction, conduct of SBIRT and incorporation into work-flow, introduction to medication assisted treatment using FDA-approved medications, and referral guidelines for the complex care team and higher level addiction care services. Implementation of this program necessitated the recruitment and hiring of additional staff in the areas of primary care and nursing as well as reallocation and remodeling of physical space within the main clinical site to allow for efficient performance of medical and administrative duties. CHS embraced its role as a community provider and partnered with multiple local and state agencies, including Recovery Courts, local hospitals and other substance use disorder treatment providers, State Substance Abuse Services administration, and city, county, and state public health authorities to make these services widely known and available to patients in need. With implementation of the program, the complex care team plans to enroll patients receiving medication assisted treatment or other non-medication addiction treatment services; patients will be referred from primary care and behavioral health providers as a direct result of SBIRT implementation; and community partners will refer individuals for treatment at CHS. Data collection regarding treatment retention, relapse rates, neonatal outcomes, and psychiatric and medical co-morbidity treatment is ongoing and will stimulate redirection of the program as indicated.

    Mark A. McGrail

    MD

    Mark A. McGrail, M.D.Director, Addiction Medicine ServiceCherokee Health SystemsDiplomate, American Board of Family Medicine and American Board of Addiction MedicineDr. McGrail received his undergraduate degree from the University of Maryland at Baltimore and his medical degree from the Uniformed Services University.  He completed a family medicine residency at Eisenhower Army Medical Center and a fellowship in Primary Care Behavioral Medicine at the University of Tennessee Medical Center in Knoxville.  Dr. McGrail retired from the U.S. Army in October 2016 after a 34 year career during which he served in multiple operational and clinical leadership positions.  He then joined Cherokee Health Systems in Knoxville, TN as the Director for Addiction Medicine Services and provides addiction and primary care to a largely underserved patient population.

    Suzanne Bailey

    PsyD

    Suzanne Bailey, PsyD is the Director of Integrative Services at Cherokee Health Systems, a comprehensive community healthcare organization in east Tennessee. Dr. Bailey leads Cherokee's integrated care implementation, provides leadership, oversight, and guidance on clinical services, and is involved in consultation and training in integrated care.  Dr. Bailey serves as the Associate Training Director for Cherokee’s APA accredited Predoctoral Psychology Internship and Behavioral Medicine Fellowship.  She earned her doctorate at Xavier University.

  • Vermont Hub and Spoke Model of Care for Opioid Use Disorders (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    Vermont established a Chronic Care Initiative that made opioid use disorder part of the Blueprint for Health and designated funding for an integrated model of care linking medical providers with regional Opioid Treatment programs (designated as hubs) and provided Community Health teams to assist buprenorphine prescribers (designated as spokes) in their practices. We describe this model and successes showing total increase in treatment enrollees, increase in number of physicians waived to prescribe buprenorphine and numbers of patients per provider, provision of a triage tool to determine hub or spoke placement and use of a learning collaborative to increase overall knowledge base statewide for opioid use disorder treatment.

    The Vermont Hub and Spoke Model is an integrative state-wide model of care to create a seamless system of treatment for opioid use disorders similar to other chronic illnesses. State wide stakeholders, addiction medicine providers, and health department officials joined together to create this system and the funding mechanism to create it will be described. Hubs were renamed from Opioid Treatment Programs and Spokes were created from office based buprenorphine prescribers and linked in each region of the state. It created regional Hub and spoke connections so that no one would lose care if they became unstable and Hubs would provide consultation and expertise to community buprenorphine providers when needed. MAT teams were created to support buprenorphine prescribers in the office setting and to increase the provider satisfaction in prescribing buprenorphine. Hubs were allowed to use buprenorphine so that people could start in a hub and go to a spoke or go from a spoke to a hub if unstable. Creation of community health teams known as MAT teams (medication assisted treatment) was key to the adoption of the model by buprenorphine providers and the roles of these teams will be explained. Finally, increases in the number of DATA 2000 waivered physicians and the patients they served will be reviewed as the overall penetration of MAT in Vermont exceeded 1% of the total population.

    John Brooklyn

    MD

    Dr. John Brooklyn is Board Certified in Family Medicine and Addiction Medicine. He is Associate Clinical Professor of Family Med and Psychiatry at the University of Vermont College of Medicine and is Medical Director of UVM Substance Abuse Treatment Center with major research interests in heroin and cocaine use and directed multiple studies of buprenorphine past and currently. He helped create the first program in Vermont for treating pregnant opioid users. He currently is the Medical Director of 3 of the opiate treatment programs in Vermont. He is a statewide and national consultant to doctors for methadone and buprenorphine treatment. He conceived of the Hub and Spoke Model in Vermont.He is the former medical director and current staff physician at the Community Health Center in Burlington for 23 years. He is an avid bicyclist and skier and has 3 grown children.

    Anthony Folland

    BA

    Tony Folland is the Clinical services Manager and State Opioid Treatment Authority for Vermont. Prior to the last 7 years in state government,  he was employed in the social services field for nearly 20 years, having worked in both rural and urban mental health centers in a variety of capacities including: emergency services, outpatient treatment and case management, program development and staff supervision, Drug treatment courts and Medication Assisted Treatment for opioid use disorders. 

  • A Low Threshold Clinic for Medically Complex Patients with Substance Use Disorder (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    The Mass General Bridge Clinic is an immediate access clinic which provides low threshold transitional support and treatment to patients following hospitalization or directly from the emergency department (ED) and other outpatient clinics. The clinic predominantly serves individuals who would otherwise be unable to access care. The goal of the clinic is first and foremost engagement, followed by rapid treatment initiation, stabilization, and linkage to community-based treatment. This focus session will describe the nuts and bolts of starting and running this type of a clinic model, review lessons learned, and discuss early outcomes.

    Building Bridges in Times of Crisis: an urgent care and post discharge clinic for medically complex patients with addiction Massachusetts is among the states hit hardest by the opioid epidemic, with an estimated 1,659 lives lost in Massachusetts in 2015. The expected death toll for 2016 is even higher. In the context of the current crisis, low threshold treatment models which target high risk populations are needed. Recent Department of Public Health data found that starting pharmacotherapy for opioid use disorder following a non-fatal overdose reduced the risk of death in the subsequent year by more than 50%, yet less than 5% of those who survive overdose begin treatment. Overdose risk increases after periods of reduced tolerance, including hospitalization. Despite the risks, a minority of patients engage in addiction treatment following hospital discharge. The Mass General Bridge Clinic is an immediate access clinic which provides low threshold transitional support and treatment to patients following hospitalization or directly from the emergency department (ED) and other outpatient clinics. The clinic predominantly serves individuals who would otherwise be unable to access care. The goal of the clinic is first and foremost engagement, followed by rapid treatment initiation, stabilization, and linkage to community-based treatment. This clinic also serves in a complementary role to an inpatient addiction consult team, providing ongoing care to patients started on addiction pharmacotherapy in the hospital and allowing a pathway for same-day initiation of pharmacotherapy for ED patients. The clinical care team is multidisciplinary and includes an addiction medicine physician, a psychiatric nurse practitioner, a psychiatric clinical pharmacist, a recovery coach, a patient service coordinator, and a resource specialist. This focus session will describe the nuts and bolts of starting and running this type of a clinic model, review lessons learned, and discuss early outcomes. Objectives: 1. Describe the need for low threshold treatment models for medically complex patients with substance use disorder. 2. Identify the types of services and supports patients leaving an inpatient medical setting or emergency department require to enhance engagement, stabilization, and treatment success. 3. Develop a blueprint for starting innovative treatment models for high-risk and medically complex patient populations. References: 1.http://www.mass.gov/eohhs/docs... 2. D'Onofrio G, et al. JAMA. 2015. 3. Liebschutz JM, et al. JAMA Intern Med. 2014. 4. Naeger S, et al. J Subst Abuse Treat. 2016.

    Sarah Wakeman

    MD, FASAM

    Sarah E. Wakeman, MD is the Medical Director for the Mass General Hospital Substance Use Disorder Initiative, program director of the Mass General Addiction Medicine fellowship, and an Assistant Professor of Medicine at Harvard Medical School. She is also the Medical Director of the Mass General Hospital Addiction Consult Team, co-chair of the Mass General Opioid Task Force, and clinical lead of the Partners Healthcare Substance Use Disorder Initiative. She is the Medical Director of RIZE Massachusetts, a state-wide, private sector initiative created to build a $50 million fund to implement and evaluate innovative interventions to address the opioid overdose crisis. She received her A.B. from Brown University and her M.D. from Brown Medical School. She completed residency training in internal medicine and served as Chief Medical Resident at Mass General Hospital. She is a diplomate and fellow of the American Board of Addiction Medicine. She is chair of the policy committee for the Massachusetts Society of Addiction Medicine. She served on Massachusetts' Governor Baker’s Opioid Addiction Working Group. Nationally, she is chair of the American Society of Addiction Medicine Drug Court Task Force and serves on their ethics committee.Clinically she provides specialty addiction and general medical care in the inpatient and outpatient setting at Mass General Hospital and the Mass General Charlestown Health Center. Her research interests include evaluating models for integrated substance use disorder treatment in medical settings, recovery coaching, physician attitudes and practice related to substance use disorder, and screening for substance use in primary care.

    Laura G. Kehoe

    MD, MPH, FASAM

    Dr. Kehoe is an Assistant Physician at Massachusetts General Hospital and an Assistant Professor of Medicine at Harvard Medical School and is board certified in both Internal Medicine and Addiction Medicine.  She attended Tufts University School of Medicine and Boston University School of Public Health and completed her residency in Internal Medicine at Massachusetts General Hospital.   At Massachusetts General Hospital, she is the Medical Director of the Substance Use Disorder Bridge Clinic, an immediate access, urgent care addiction program.   She is actively involved in medical student and resident education as an attending physician on the inpatient Addiction Consult Team (ACT), and she is the co-chair of the hospital-wide Substance Use Disorder Education Committee, where she works with other team members to expand evidence-based treatment of patients with addiction. 

    Outside of MGH, she was the Medical Director of Baycove Treatment Center for Opiate Addictions Methadone Maintenance program and she treats patients as part of a multidisciplinary addiction team at the supportive housing and outpatient non-profit, Right Turn.   Lastly, Dr. Kehoe is a founding member of W.A.T.E.R.town (Watertown Access to Treatment Education and Recovery), a community coalition working to expand prevention, intervention and treatment for people with substance use disorder in Watertown, MA.

    Jessica L. Moreno

    PharmD, BCPP

    Dr. Jessica Moreno is a Board-Certified Psychiatric Pharmacist in a co-funded faculty role at Northeastern University and her clinical practice site is at Massachusetts General Hospital where she works on the inpatient Addictions Consult Team and in the outpatient Bridge Clinic. The MGH Bridge Clinic is a post-discharge clinic that provides transitional addiction treatment to patients following release from the hospital or the emergency department while working to establish longitudinal community-based care. She received her BSE in Chemical Engineering and Doctor of Pharmacy at the University of Michigan. She completed a post-doctoral industry fellowship program at Massachusetts College of Pharmacy and Health Sciences in conjunction with Cubist Pharmaceuticals. She then went on to complete a PGY1 pharmacy residency at the Ann Arbor VA Medical Center and PGY2 psychiatric pharmacy residency at the William S. Middleton VA Hospital in Madison, WI.  Her clinical role exclusively involves patients with substance use disorders. She makes treatment recommendations to the interdisciplinary teams she works with and, in the outpatient setting, she is developing clinical pharmacy services with the ultimate goal of having collaborative drug therapy management. Her faculty role consists of teaching Doctor of Pharmacy students in the experiential setting at her clinical practic site as well as developing and delivering the psychiatric lectures in a core curriculum course called Comprehensive Disease Management at Northeastern. Regarding research, she is currently the primary investigator on three retrospective studies that will be used as foundations for future prospective, randomized research in the field of substance use disorders. 

  • The Relief That Binds You: Pain Induced by Opioid Use and Withdrawal (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    This session will provide participants with an overview of the literature on pain from opioid use and withdrawal by focusing on three topic areas: opioid-induced hyperalgesia, withdrawal-induced hyperalgesia, and withdrawal-associated injury site pain. Clinical implications for those with opioid use disorders and/or chronic noncancer pain will be discussed including risk factors and potential mitigators. Interactive case presentations will follow with participants encouraged to share their experience.

    Opioids have been used for thousands of years to relieve both physical and emotional suffering. Yet exposure due to an opioid use disorder or through prescription use for chronic non-cancer pain can alter the nervous and immune systems resulting in more pain sensitivity, termed opioid-induced hyperalgesia (OIH) (1,2). When opioids are stopped the underlying pain sensitivity can be revealed, exacerbated by other withdrawal features to produce even more pain termed withdrawal-induced hyperalgesia (WIH). Both OIH and WIH appear to be both dose dependent and withdrawal episode dependent (3,4). Recently, the presenter and colleagues reported in a mixed methods study a novel opioid pain phenomenon involving the reactivation of old healed injury site pain during opioid withdrawal (5). This withdrawal-associated injury site pain (WISP) was shown to be a barrier to opioid detoxification and a risk factor for relapse. Clinicians need to understand these opioid related phenomena to better educate and treat their patients. This 60 minute focus session will involve a didactic overview of key studies on OIH, WIH, and WISP, including mechanisms and possible treatments. Then cases will be presented from the author's research and clinical experience. Participants will be encouraged to share their own cases along personal experiences to round out the interactive discussion. By the end of the session participants will be able to list three pain phenomena associated with opioid use or cessation identified in the literature beyond generalized withdrawal myalgias and arthralgias, discuss possible mechanisms for opioids increasing pain with use and withdrawal, and identify potential mitigators of opioid associated pain based on current evidence that may be relevant for clinical practice. With the opioid crisis looming world-wide, it is important to understand problems related to opioid use and barriers to opioid detoxification. Pain caused by opioid use and withdrawal appears to be a key factor in perpetuating opioid use. Finding practical evidence based solutions is vital now and going forward. This focus session will provide material that can advance participants' knowledge and skill in management of opioid related pain phenomena.

    Launette Marie Rieb

    MD, MSc, CCFP, FCFP, DABAM, FASAM

    Dr. Launette Rieb is a Clinical Associate Professor in the Department of Family Practice at the University of British Columbia (UBC), Canada. She is a Family Physician and diplomat of The American Board of Addiction Medicine. She did her graduate work in the area of pain physiology. She completed a postgraduate UBC Clinical Scholar's Program in 2015 and a NIDA sponsored Canadian Addiction Medicine Research Fellowship in 2016 resulting in publication on a newly described opioid pain phenomenon - withdrawal-associated injury-site pain (WISP). She has also published on fentanyl and heroin overdose deaths in BC, as well as on addiction in a variety of marginalized populations. Dr. Rieb is the Medical Director of a multidisciplinary team at OrionHealth (Vancouver Pain Clinic), and works as a consultant for the Rapid Access Addictions Clinic at St. Paul’s Hospital in Vancouver. In addition, she does addiction medicine consultations for The Orchard Recovery Centre, on Bowen Island. Dr. Rieb has taught addiction medicine in the undergraduate and postgraduate medical programs at UBC, and at national and international conferences for 24 years. Dr. Rieb was the co-creator and initial Physician Director of the St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship (now the BC Centre on Substance Use Addiction Medicine Fellowship). She is a member of the Canadian Society of Addiction Medicine’s Education Committee and the College of Family Physician of Canada's Competency Creation Working Group for the Certificate of Added Competency in Addiction Medicine. Dr. Rieb is the past recipient of a UBC Faculty of Medicine Post Graduate Teaching Award. 

  • Thriving Under Value-Based Reimbursement with Behavioral Screening and Intervention (BSI) (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    As value-based reimbursement continues to expand, healthcare organization leaders increasingly appreciate the importance of behavioral health but aren’t sure what to do about it. Simply hoping that providers will recognize and treat or refer patients for behavioral health issues will no longer “cut it.” In this session, attendees will learn how to advise healthcare leaders on Behavioral Screening and Intervention, an evidence-based, cost-saving, proactive approach to identifying and addressing behavioral risks and disorders.

    Healthcare organizations across the nation are scrambling to adapt to value-based reimbursement. Most healthcare leaders know that behavioral health is important, but they aren't sure what to do about it. This is a huge opportunity for addiction treatment professionals who can offer solutions beyond conventional referral resources. Under MACRA, primary healthcare settings must choose to be reimbursed through alternative payment models (APMs) such as accountable care organizations (ACOs), or through the Merit-based Incentive Payment System (MIPS). Under bundled payment programs, Medicare will provide one lump-sum reimbursement for patients with certain conditions, regardless of actual costs. Under APMs, MIPS and bundles, the financial well-being of healthcare organizations will hinge on their success at improving health outcomes and controlling healthcare costs across large populations of patients. Behavioral health issues are key determinants of outcomes and costs. Simply hoping providers will recognize and treat or refer patients for behavioral health issues will no longer cut it. A proactive, population-wide approach is necessary. That approach is behavioral screening and intervention (BSI). All patients are systematically screened for key behavioral risks and disorders. Healthcare teams are expanded with coaches, who have the training and time to provide robust, evidence-based interventions - motivational interviewing and behavior change planning for smoking and unhealthy drinking and drug use, and collaborative care for depression. Although coaches and primary care providers can handle most issues, BSI will generate more referrals for mental health and addictive disorders. This session will cover the prevalence, health effects and economic impacts of behavioral issues. It will define and describe the process of BSI. It will cite research on the effectiveness and cost savings of components of BSI. It will describe how BSI was implemented at dozens of healthcare settings in Wisconsin and the results - high patient satisfaction, substantial improvement in behavioral outcomes, and nearly $800 two-year, net healthcare cost savings per Medicaid patient screened. It will describe how BSI can serve as the framework for primary care/behavioral health integration and the hub for chronic disease management. The participants will learn how to advise healthcare organizations on integrating BSI into a variety of general healthcare settings, enhance their credibility as systems-level behavioral health consultants, and help their organizations thrive under value-based reimbursement.

    Richard L. Brown

    MD, MPH

    Dr. Brown is a family physician and a tenured full professor in the Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin. His academic focus has been the primary care management of alcohol and drug disorders and other behavioral risk factors and conditions. He has conducted NIH-funded research, published dozens of peer reviewed articles, made numerous presentations, and conducted workshops in these realms on four continents. He served as president of the Association for Medical Education and Research in Substance Abuse (AMERSA) from 1997 to 1999 and received AMERSA's McGovern award for excellence in medical education in 2002. From 1999 to 2004, he served as the founding director of Project MAINSTREAM (www.projectmainstream.net), a federally funded program that enhanced substance abuse education for twelve health professions and improved education for over 10,000 trainees. Since 2006, he has served as Director for the Wisconsin Initiative to Promote Healthy Lifestyles (www.wiphl.com). WIPHL has helped 40 general healthcare settings provide over 110,000 screens and 25,000 interventions, garner excellent patient satisfaction, and elicit substantial declines in risky and problem drinking. Dr. Brown is owner and CEO of Wellsys, LLC (www.wellsys.co), which provides software, consulting, training and clinical support to enable healthcare settings to provide systematic, evidence-based, cost-saving screening and intervention services for the behavioral risks and disorders responsible for over 40% of deaths, most chronic disease and disability and nearly $1 trillion in costs per year.

  • Use and Interpretation of Buprenorphine Metabolite Profiles During Maintenance Treatment (1 CME)

    Contains 3 Component(s), Includes Credits

    Using urine buprenorphine and metabolite levels to provide insight into treatment compliance, adulteration and misuse of buprenorphine.

    Urine drug testing during medication-assisted treatment with buprenorphine involves not only assessment for illicit and non-prescribed substances but also involves confirmation of appropriate use of buprenorphine. While standard urine drug screens provide a glimpse into individual patient drug use patterns, the buprenorphine/metabolite levels provide insight into compliance; adding the urine creatinine (Cr) allows for standardization of levels despite fluctuations in urine concentration. Trending the total buprenorphine and metabolite profiles, and comparing the buprenorphine metabolite-Cr ratios, provides information about how the patient is taking their medication. Profiles can also be used to detect urine adulteration (e.g. urine spiked with buprenorphine) and misuse. The presence of appropriate levels of buprenorphine and metabolites, when standardized to urine Cr, are evidence of compliance over time. A compliant patient will have fairly low levels of buprenorphine and higher levels of the metabolites (norbupnor buprenorphine/Cr). Someone with intermittent buprenorphine use will have much lower metabolite levels than someone maintained on stable doses taken daily. Adding medication to the urine results in a very different profile than stable dosing with very high buprenorphine levels (Tbup/Cr >4000 ng/mg Cr), naloxone in the urine, and negligible Tnorbup/Cr levels. This indicates that the medication, the buprenorphine/naloxone, was put directly into the urine. While tests must be interpreted in the context of patient self-report and other information such as attendance, participation in group and counseling activities, and reports of progress from family, spouse, counselors and other reliable sources, the confirmation and quantification of urine buprenorphine and metabolite levels can suggest deviations and inconsistency with dosing over time. They can also be used to confirm compliant dosing. Appropriate use and interpretation can help providers anticipate and then mitigate untoward complications of therapy. This session involves didactic based presentation including a review of buprenorphine metabolism and elimination. Interpretation of drug testing results involving detection and quantification of various buprenorphine metabolite profiles is done through case-based discussion using examples from my clinical practice, in which interpretation of these levels was used to guide therapy. Specific cases involving compliant patients from induction to stabilization are compared to illicit and street use profiles. Examples of substitution and adulteration are presented. Questions will be posed to the audience using an Audience-Response-System and interactive discussion is included in order to best answer the questions and present the material. In addition to test interpretation appropriate testing frequency and use of alternative matrices (e.g. saliva/oral testing) was compliment to urine testing is covered. This material is in follow-up from a previous presentation on buprenorphine metabolite profiles in urine drug testing which was presented in abstract and poster format at the 2016 ASAM Conference in Baltimore, MD (1). Effective use of urine drug testing requires not only the right test with appropriate components but also knowledge of the pharmacologic principles of metabolism and elimination. Appropriate testing can reinforce compliance, and deter medication misuse and diversion. Testing during addiction treatment, in buprenorphine maintenance, is part of a primary prevention and disease management program.

    Timothy J. Wiegand

    MD, FACMT, FAACT, FASAM

    Tim Wiegand MD, DABAM, FACMT, FAACT was trained in internal medicine and completed fellowship training in Medical Toxicology at the University of California, San Francisco in 2006. He was the Medical Director of the Rochester Poison Center until 2010. Dr. Wiegand has been successful in developing a full time, bedside, medical toxicology consultation service and is very active in the practice of Addiction Medicine, having successfully completed his board certification recently. 

    In addition to his primary appointment as Associate Professor of Emergency Medicine at the University of Rochester School of Medicine & Dentistry in Rochester, NY, Dr. Wiegand serves as Medical Director for Huther Doyle Chemical Dependency Treatment Program in Rochester, NY and as a detoxification specialist for Syracuse Behavioral Health in Rochester, NY. 

    Dr. Wiegand serves on the New York Society of Addiction Medicine (NYSAM) Board of Directors as the Communication Committee Chair and he was recently elected to the American College of Medical Toxicology Board of Directors to begin a 3 year term in October, 2015. He currently serves as the chair of the Addiction Medicine Section for the American College of Medical Toxicology and he recently organized a very successful Addiction Medicine Academy for ACMT prior to their main Annual Scientific Meeting in Clearwater, Florida in March, 2015. Dr. Wiegand has presented for the ASAM Review Course on Pharmacology & Toxicology, MRO and drug testing principles at previous Review Course conferences.

    Martin Siegrist

    RPA-C, LAc

    Martin Siegrist RPA-C, L.Ac. attended the University of Rochester and graduated in 1984.  He received his PA credentials from the SUNY Stony Brook in 1991. Martin has been working the field of addiction for 25 years including inpatient detox, inpatient rehab as well as outpatient addiction medicine. He is currently the Assistant Medical Director of Huther Doyle, an outpatient substance use disorder treatment program in Rochester, NY.

  • Using Project ECHO to Spread Office-Based MAT: Life-Saving System Transformation (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    In this presentation, we will review a brief history of the separation of addiction treatment from the medical establishment. We will introduce the Harm Reduction model, and compare how that model fits with traditional treatment models as opposed to with Medication-Assisted Treatment (MAT). We will share our process of building a MAT program in a rural primary care network, including our use of the Extension of Community Healthcare Outcomes (ECHO) model to build competency in including MAT as part of comprehensive primary care.

    Opioid addiction is an increasing problem in the United States. Effective treatment options exist, but are often challenging to access, especially for patients who live in remote, rural areas. There is a long history of separation of treatment of addiction and medicine, and certainly a disconnect between primary care and treatment for opioid addiction. Included in the reasons for separation from primary care are special training and licensing requirements, and a paucity of education regarding primary care-based treatment options for patients struggling with opioid addiction. Office-based treatment with buprenorphine is an evidence-based approach to helping patients with opioid addiction avoid illicit opioid use and re-engage with a meaningful and productive life. However, effective implementation requires that health system administration, primary care physicians, and primary care staff both overcome decades of stigma and learn how to safely administer treatment, while also running an efficient and patient-centered comprehensive primary care clinic. Like many potentially effective treatments, both pharmacological (e.g., anti-depressant medications) and behavioral (e.g., time-outs for unwanted behavior from children), it is essential that the treatment be properly executed to maximize positive outcomes. Project ECHO (Extension of Community Healthcare Outcomes) started as an innovative approach to increasing access to effective treatment for hepatitis C to rural, community-based care clinics in New Mexico. The project was a success, with patients receiving care in primary care centers demonstrating outcomes that were as good as those for patients getting care from a specialist, but from a center that was much more convenient to access. It used a hub-and-spoke video conferencing model to connect community primary care clinics both with an expert team (hub) and one another (spokes). This model allowed specialty knowledge to spread from the hub to the spokes, as well as practical, primary-care focused expertise to be shared between the various primary care teams participating (spokes). Following the success of the original project, the ECHO model has spread to other states, and been used to spread other times of specialty care knowledge in an effort to exponentially increase capacity to treat, and reduce health care inequities. In this presentation, we will review a brief history of the separation of addiction treatment from the medical establishment. We will introduce the Harm Reduction model, and compare how that model fits with traditional treatment models as opposed to with Medication-Assisted Treatment (MAT). We will review data relevant to MAT, in regards to outcomes as well as risks of treatment. We will share our process of building a MAT program in a rural primary care network, as well as discussing complementary components of a comprehensive effort to reduce rates of addiction. We will share available data from the project-in-progress, and encourage audience members to engage with us in discussion, about both the process of building such a program, as well as the risks and benefits of this approach to treating opioid addiction.

    James B. Anderson

    PhD

    James B. Anderson, PhD, Licensed Psychologist, Leatherstocking Healthcare Collaborative Partnership & Bassett Healthcare Network, completed his PhD in Clinical Psychology at Western Michigan University in 2010, and a Postdoctoral Fellowship in Primary Care Integrated Behavioral Health at the University of Massachusetts Medical School in 2012.   He has been an assistant professor at the University of Massachusetts Medical School, and the co-director of Behavioral Science for the Family Medicine Residency at Hennepin County Medial Center in Minneapolis, Minnesota.  He currently serves as the New York State Medicaid Delivery System Reform Incentive Payment (DSRIP) program, and works as a clinical psychologist providing integrated prinary care behavioral health services for Bassett Healthcare Network in Upstate New York.

    Stephen A. Martin

    MD, EdM

    Stephen Martin, MD, EdM, is an Associate Professor of Family Medicine and Community Health at the University of Massachusetts Medical School.  He also serves as residency faculty at Boston University School of Medicine and is a member of the faculty at Harvard Medical School’s Center for Primary Care.  He is a graduate of Williams College, the Harvard Graduate School of Education, Harvard Medical School, and a residency in Family Medicine at Boston University.

    After four years with the National Health Service Corps in a community health center and federal prison medical center, Steve’s clinical site has been the Barre Family Health Center, a source of health care for ten rural towns.  He is on the faculty for the center’s 12 residents and co-directs the University of Massachusetts’ Rural Health Scholars Program and the UMass Project ECHO for Opioid Use Disorder.  He is founding project director of TandemHealth , a partnership between Consumer Reports and the National Physician Alliance to develop independent electronic resources for training and practicing clinicians as well as patients.  In 2013, he was named Preceptor of the Year by the Massachusetts Academy of Family Physicians.  Steve is the lead author of publications in the BMJ, JAMA, Lancet, and the American Journal of Public Health.
    He is a member of the RightCare Alliance Primary Care Council and co-founder of Care that Matters. His chief professional goal is to redress the Inverse Care Law.

    Joseph R. Sellers

    MD, FAAP, FACP

    Joseph R. Sellers MD, FAAP, FACP is a practicing Internist and Pediatrician who serves as the Eastern Region Medical Director for the Bassett Helthcare Network in Upstate New York. Dr. Sellers is the lead physician for a New York Medicaid - Delivery System Reform Incentive Program project to integrate medical assisted treatment for opioid abuse into primary care practices and to improve colaboration between primary care  medical providers and community substance abuse programs.

    Dr. Sellers is a graduate of the University of Rochester and the Georgetown University School of Medicine. He completed his residency in Internal Medicine and Pediatrics at the Albany ( NY) Medical Center. He is board certified in Internal Medicine and Pediatrics and is a Fellow of the American Academy of Pediatrics and the American College of Physicians.Dr, Sellers is an Assistant Clinical Professor of Medicine at the Columbia University College of Physicians and Surgeons. He serves as treasurer of the Medical Society of the State of New York, is a member of the Schoharie County ( NY) Board of Health, the Board of Trustees of Cobleskill Regional Hospital and the Executive Board of the  Leatherstocking Council, Boy Scouts of America.

    Daniel Mullin

    PsyD

    Daniel Mullin, PsyD is an Associate Professor at the University of Massachusetts Medical School.

  • Teamwork Training to Enhance Effectiveness and Patient Safety in Addiction Medicine (1 CME)

    Product not yet rated Contains 3 Component(s), Includes Credits

    The presenters will provide an introduction to the concepts of teamwork enhancement as it may apply to care providers within the field of addiction care. Attendees may identify areas in which opportunities for improvement exist in their current or past working environment.

    Few areas in healthcare depend upon effective teamwork as much as addiction medicine. Providers from medical, nursing, social work, and administrative personnel inevitably function in teams that must provide comprehensive care to patients with multiple and diverse needs. However, care may be compromised if teams do not function successfully. Fragmentation of care and limited coordination lead to inadequate and poor quality care, patient safety concerns, low patient satisfaction and program drop-out. Constricted or limited communication lines may additionally compromise the care provided. Furthermore, operational inefficiencies increase costs, decrease employee satisfaction, leading to higher employee turn-over and burnout. Everyone loses. TeamSTEPPS represents a proven, effective tool for the development of teams in healthcare. It is designed to improve patient care through enhanced teamwork. While TeamSTEPPS was originally designed in the military over 20 years ago, it has been widely adapted for hospital-based work, it has since been applied to a number of outpatient settings, including physician office practice settings, with success. TeamSTEPPS is also known to improve team efficiencies and enhance worker satisfaction. The presenters will provide an overview of team functioning rules to help organizations and individuals recognize the opportunities to provide safer and more effective care. This 60-minute workshop is very interactive with multiple video clips and audience involvement to engage all participates in building and practicing good techniques. Those in attendance will leave this workshop with multiple, easily deployed, first "stepps" towards building enhanced competencies in functioning in teams.

    Charles W. Schauberger

    MD, MS, CPE

    Dr. Charles Schauberger is an obstetrician who practices at Gundersen Health System in La Crosse, Wisconsin. He attended University of Iowa Medical School and completed a residency in Obstetrics & Gynecology at the same location many years ago. He received a MS in Administrative Medicine from the University of Wisconsin- Madison. He has published over 40 articles in the peer review literature. He is passionate about the care of pregnant women with addictions.

    Grena Porto

    RN, MS, ARM, CPHRM

    Grena is a nationally recognized expert and leader in patient safety, risk management and quality improvement.  Grena has over 25 years’ experience in all areas of risk management, including loss prevention, risk financing and claims management. She served as regional claims manager for a large national insurer, and was also director of risk management at a large academic medical center in New York. Early in her career she served as risk management coordinator for a 10-member group captive in New York City. She also was employed as a professional liability claims analyst for a well-known third-party administrator. More recently, she operated her own healthcare risk management consulting firm for 10+ years and also served as Sr. Vice President and Client Executive for a large multinational brokerage firm.

    She is a past President of the American Society for Healthcare Risk Management (ASHRM) and has served on the Board of Directors of the National Patient Safety Foundation (NPSF). She currently serves on the Joint Commission's Patient Safety Advisory Group. 
    Grena is also a Distinguished Fellow of ASHRM and has also attained the designations of Associate in Risk Management (ARM) from the Insurance Institute of American, and Certified Professional in Healthcare Risk Management (CPHRM) from the American Hospital Association. She holds a Bachelor of Science in Nursing and Master of Science in Health Administration from the State University of New York at Stony Brook. Grena has lectured extensively both nationally and internationally, and is the author of numerous publications on risk management and patient safety.