Being and Becoming a Rural MOUD Provider: Live Sessions

• The below 2021 study presents reassuring data on drug-drug interactions with the Sublocade 
  • Evaluation of Drug‐Drug Interaction Liability for Buprenorphine Extended‐Release Monthly Injection Administered by Subcutaneous Route
• Findings In this cohort study using difference-in-differences analyses of 17 428 Medicaid-enrolled adults with an opioid use disorder emergency department encounter, the buprenorphine treatment O-HQIP pathway was associated with significantly increased prescription fills for buprenorphine within 30 days of discharge.
  • Association Between Hospital Adoption of an Emergency Department Treatment Pathway for Opioid Use Disorder and Patient Initiation of Buprenorphine After Discharge
• ASAM Literature Review Article – Clinical Considerations Buprenorphine

• This retrospective chart review quantifying precipitated withdrawal (N=13). You have to look at the supplementary data to find out this is 13 out of 931 charts which is 1.4%. 

• Gail D’Onofrio’s prospective study of precipitated withdrawal in the ED. This study found the incidence of precipitated withdrawal to be less than 1% despite high fentanyl prevalence.

• Initiating Buprenorphine during Pregnancy

This national guidance document for the treatment of pregnant and parenting people with OUD is very comprehensive. It is organized by clinical fact sheet with recommendations followed by deeper exploration of the evidence and nuances. 

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants (samhsa.gov)

The CA Bridge Program has a very concise and well cited protocol for medication initiation in pregnancy. CA Bridge is intended for Emergency Departments but can still serve as a reference for other outpatient settings (acep.org). Visit their website for tons of other great resources.

• Ketamine-assisted buprenorphine initiation: a pilot case series

• Jail communications
  • We also spoke briefly about the experience of another grantee who gets notifications when there is a new person incarcerated at their jail and is able to “reach in” to make contact with them through the jails controlled communication system. This is the system she described using: Friends and Family - Cidnet. Note, this mention does not constitute an endorsement of this product.

• This is a recent, especially relevant resource from PCSS that addresses much of the uncertainty around initiating buprenorphine for people using or consistently exposed to fentanyl.
  • Practice-Based Guidelines: Buprenorphine in the Age of FentanylBuprenorphine in the Age of Fentanyl
• This is the retrospective chart review quantifying precipitated withdrawal (N=13). You have to look at the supplementary data to find out this is 13 out of 931 charts which is 1.4%.
• This is Gail D’Onofrio’s prospective study of precipitated withdrawal in the ED. This study found the incidence of precipitated withdrawal to be less than 1% despite high fentanyl prevalence.
• Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl

• Key take aways from this review article are: no antipsychotic has demonstrated superiority for the management of chronic psychosis due to methamphetamine. Clozapine may help those patients whose psychosis is resistant to antipsychotics. Benzodiazepines can provide relief in acute psychosis but may not be beneficial for methamphetamine induced psychosis. One study of 5 people showed a reduction in both positive and negative symptoms with minocycline
  • A Narrative Review of the Pathophysiology and Treatment of Methamphetamine-Associated Psychosis | International Journal of Mental Health and Addiction

• Article from 2023 that goes over some of the challenges with provider recruitment in rural areas. 
  • Strategies to recruit rural primary care providers to implement a medication for opioid use disorder (MOUD) focused integrated care model
• Sample policy and procedure for MOUD delivery
  • I found some policy and procedure exemplars. Beware I have not fully vetted these but upon a quick review I see no red flags. These are all several years old and would need to be tailored to your own setting/community but they can serve as a starting point.  
  • MAT-procedure-11.15.19.pdf (careinnovations.org)
  • MAT-Workflow.pdf (jeffersonhealthcare.org)
  • This one is for corrections: Buprenorphine Prescription Policy (iphca.org)
  • The National Clinical Guidelines from ASAM have some guidance on MOUD in the context of liver disease. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder
  • This video explains the different medications available for treating opioid use disorder and how they work to support recovery. Effective Treatments for Opioid Use Disorder: Finding Recovery and Staying Safe (NEJM)
  • This video covers best practices for delivering care, focusing on diagnosis, harm reduction strategies, and the use of medications in primary care settings. Treating Opioid Use Disorder in General Practice: Diagnosis, Harm Reduction, and Medications (NEJM)
• American Osteopathic Academy of Addiction Medicine Hot Topics series. The slides from one of their presentations is attached as an example. This slide set contains some discussion of adjuvant medications for opioid withdrawal.

• Stigma reduction training
  • A participant discussed using this training with program staff: Reducing Stigma Education Tools (ReSET) | Dell Medical School | The University of Texas at Austin (utexas.edu). This high-quality training is free, takes about 1.5 hours, and provides CEUs. Bridge to Treatment also has useful tools Reducing Stigma & Changing Culture - Bridge to Treatment and a team training package that is intended to be delivered live to a team. It includes the videos and exercises necessary to conduct the training. People First: A Team Approach to Stigma Reduction - Bridge to Treatment.

• ADHD AND STIMULANT USE DISORDER
  • The Wender Utah Rating Scale (WURS), is used to retrospectively assess childhood behaviors related to ADHD in adults. It consists of 61 questions focusing on traits like attention issues, impulsivity, and emotional regulation, scored on a 0-4 scale. A score above 46 indicates a likelihood of ADHD, helping healthcare providers differentiate ADHD from other conditions.
  • Access the full document here: Wender Utah Rating Scale: (https://www.mcstap.com/docs/wender.pdf).
  • A useful companion for this screening tool is the Adult self-assessment scale.
  • The current national guidelines for management of stimulant use disorder recommend management of co-occurring ADHD with pharmacotherapy including psychostimulant medications.

• PCSS is a great resource for both new and seasoned providers. They also offer a free mentor program, along with the ability to join an online discussion forum and submit a clinical question. 
  • Providers Clinical Support System (pcssnow.org)
• The other clinical resource we discussed regarding starting buprenorphine was CA Bridge which is rebranding itself as Bridge to Treatment. Their website is loaded with resources and trainings. I attached a pdf of all their protocols in one packet. You can download each protocol separately from their website if you want to be selective about what you share so you don’t overwhelm anyone. 
  • Bridge to Treatment (https://bridgetotreatment.org)
• Mobile Unit Examples: Keep in mind the attached resources were developed between 2020-2021 timeframe to include the below toolkit. You can look at the materials and decide if any of the information is helpful to you or your grantees. 
  • Rural Health Information Hub: Mobile Units Examples and Toolkit

• Boston Clinical Guidelines: Example intake forms etc. 
  • Office Based Addiction Treatment Training and Technical Assistance
• National Clinician Consultation Center Substance Use Warmline
  • M-F 6am-5pm PT. Voicemail 24 hours a day, 7 days a week.

                    Specialty addiction medicine consultation

                    (855) 300-3595

• The Office of the Assistant Secretary for Planning and Evaluation produced a summary report that will orient you to some of the policy issues you may encounter while implementing contingency management. This report is also attached and may be found here: https://aspe.hhs.gov/sites/default/files/documents/72bda5309911c29cd1ba3202c9ee0e03/contingency-management-sub-treatment.pdf
  • On the subject of contingency management, the attached article by Rash 2023 is a thorough implementation guide for contingency management.

• The American Society of Addiction Medicine and the American Academy of Addiction Psychiatry jointly produced practice guidelines for stimulant use disorder. They address contingency management, pregnancy, and off-label medication use. The guidelines are attached but also can be downloaded here: Stimulant Use Disorder Guideline (asam.org).

• The American Society of Addiction Medicine has created national guidelines on OUD, stimulant use, clinical drug testing, alcohol withdrawal, and managing substance withdrawal in jails. They also have guidelines on benzodiazepine tapering in development.
• Boston Medical Center OBOT Clinical Guidelines are another resource aims to support effective care delivery and improve patient outcomes. Key topics covered by this resource include:
  • Best practices for collaborative care teams
  • Guidelines for treating pregnant and parenting patients
  • Tools for prescribers, behavioral health staff, and recovery coaches

• Although this review does not address methamphetamine induced psychosis specifically, it presents studies showing clozapine alone or with risperidone may increase the likelihood of achieving lasting remission form AUD among patients with psychosis. 
  • Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder - PMC